Inflammation of the pericardium — the sac around the heart
NG-066CARDIOADHD-friendly visual edition
Inflammation OUTside the heart muscle — the two-layer sac (pericardium) that wraps the heart gets irritated, roughens, and rubs. Less cardiac output = less oxygen OUT to the body. Left untreated, fluid can build in that sac and squeeze the heart — that next stage is Cardiac Tamponade, NG-178.
🧨 Inflammation OUTside the heartThe sac around the heart is irritated, not the muscle itself — but output still drops.
🛏️ Worse flat, better leaning forwardPain fires up supine, eases sitting up & leaning forward — the opposite of MI pain.
👂 Friction rub = grating soundBest heard with the diaphragm, left sternal border, client leaning forward.
🚨 Watch for tamponadeFluid can build in the sac → Beck's triad → NG-178. Report new muffled heart sounds.
🧨
CAUSE
STEP 1 · THE IRRITATED SAC
One structure explains the whole disease — the pericardium is a two-layer bag with a thin film of fluid between the layers so the heart can slide and beat without friction.
🫀 Normal → inflamed → fluid-filled: the same sac, three stages
EXAM TIP Pericarditis, effusion, and tamponade are one continuum — the same pericardial sac getting worse. Know where a client sits on this line and you know what to do next.
🧠 "A wet balloon inside a paper bag." The heart is the balloon, the pericardium is the bag. A little lubricant is fine — irritate the bag (pericarditis) and it rubs; fill the bag with water (effusion) and it strangles the balloon (tamponade). Same bag, three chapters of the same story.
⚠️ Causes — what irritates the sac
🦠 Infection — viral is the most common cause
❤️🔥 Post-MI — acute MI, or weeks later as Dressler syndrome (autoimmune reaction after cardiac injury)
🧠 "I AM U" — Infection · Autoimmune (lupus/scleroderma/RA) · MI (post-MI or Dressler) · Uremia. Whatever irritates the sac gets remembered as "I am you" — the pericardium reacting to insult.
🔤 Say the word — it tells you the disease
Peri = around 🔄
Card = heart ❤️
-itis = inflammation 🔥
Peri · card · itis = inflammation of the sac AROUND the heart — not the heart muscle (that's myocarditis) and not the inner lining/valves (that's endocarditis, NG-229).
🧠 Peri = "perimeter." The perimeter fence around the property (the heart) is what's on fire — the house itself is still standing.
🔎
CLUES
STEP 2 · SPOT IT
A grating sound plus a pain pattern that flips with position — and an ECG that looks nothing like a heart attack's.
👂 Pericardial friction rub — grating, scratchy, "leather on leather"
Caused by the two roughened, inflamed pericardial layers rubbing against each other with every heartbeat. Best heard with the diaphragm of the stethoscope, at the left sternal border, with the client leaning forward and holding their breath.
🧠 "Squeaky new leather boots." The rub sounds like two pieces of dry leather grinding together — that's exactly what two inflamed pericardial layers with no smooth fluid between them are doing.
This is the single biggest way pericarditis pain differs from cardiac/MI pain. Lying flat lets the inflamed layers press together over a larger area; leaning forward pulls the heart away from the anterior pericardium and eases the rub. Pain is often sharp, stabbing, pleuritic — it also worsens with deep inspiration, coughing, and swallowing.
Feature
🔥 Pericarditis pain
❤️ Cardiac / MI pain
Quality
Sharp, stabbing, pleuritic
Crushing, pressure, squeezing
Position
Worse supine, better sitting forward
No position makes it better
Breathing/cough
Worse with deep breath, cough, swallow
Unaffected by breathing
Radiation
Neck, shoulder, trapezius ridge
Arm, jaw, back
Associated signs
Friction rub, low-grade fever
Diaphoresis, nausea, dyspnea, ⬆️ troponin
🧠 "Sit up to shut it up." If leaning forward makes chest pain BETTER, think pericarditis. If NOTHING makes it better, think MI — call it a cardiac emergency until proven otherwise.
📈 ECG: diffuse, not localized
Pericarditis causes diffuse, concave-up ST elevation across most leads, plus PR segment depression — because the inflammation coats the whole outer heart, not one blocked artery.
🧠 "Blanket vs. bullet." Pericarditis throws a blanket of ST elevation over the whole ECG; an MI fires one bullet into one territory of leads.
🧪 Labs that confirm inflammation
🧫 WBC elevated — over 10,000
📈 C-reactive protein (CRP) — elevated
📈 ESR (erythrocyte sedimentation rate) — elevated
❤️ Troponin — may be mildly elevated if the myocardium is also irritated (myopericarditis); markedly elevated troponin points more toward MI
🧠 Inflammatory labs, not cardiac-damage labs. WBC/CRP/ESR say "something is inflamed" — they don't localize to a blocked artery the way a big troponin spike does.
🩺
CARE
STEP 3 · CALM THE SAC
Treat the inflammation, watch for fluid, drain if it builds — and never miss the jump to tamponade.
💊 Pharmacology: quiet the inflammation
Class
Drug from the source
Why
NSAIDs 💊
Indomethacin
First-line — reduces inflammation & pain
Corticosteroids 💉
Prednisone
Used when NSAIDs fail or cause is autoimmune
🧠 "NSAID first, steroid second." Start with indomethacin; save prednisone for when NSAIDs aren't enough — steroids can make some causes (like post-MI pericarditis) worse if used too early.
🚨 Pericardiocentesis — the needle in the heart sac
A needle drains fluid or blood that has collected in the pericardial sac. Not routine for simple pericarditis — reserved for a large effusion or tamponade.
🖥️ Continuous cardiac monitoring during & after
💉 Catheter often left attached to a drainage system
📋 Assess drainage type & speed — sudden drop in drainage with rising pressure = re-accumulation
🧠 See the full drainage picture on NG-178 Cardiac Tamponade — this is where pericarditis becomes an emergency.
✅ Comfort & positioning teaching
1
🪑 Sit up, lean forward — the tripod position eases pain & the rub
2
🛏️ Avoid lying flat when pain is active
3
🧊 Rest, treat fever, monitor pain trend
🧠 "Lean in to ease it." Every teaching point here is just: don't lie flat, do lean forward.
🚨 PRIORITY — watch for cardiac tamponade
As pericarditis worsens, fluid can accumulate in the pericardial sac (pericardial effusion) and eventually compress the heart. New muffled/distant heart sounds, JVD, or a falling BP = report immediately.
🧠 "Rub goes quiet = get worried." If a friction rub you've been hearing suddenly disappears, don't assume it's better — it may mean fluid has built up enough to separate the layers again. Reassess immediately.
⚡
QUICK RECALL
SAY IT OUT LOUD
🧨 Pericardium irritated= less output, still a real drop in oxygen delivery
🛏️ Flat = fire, forward = fineOpposite of MI, which no position relieves
👂 Grating friction rubdiaphragm, left sternal border, leaning forward
🚨 Fluid builds → tamponadeBeck's triad next — see NG-178
🎯 Cover & check — 4 rapid-fire questions
Q1: When is pericarditis pain worst, and when is it best?
Worst lying flat (supine); best sitting up and leaning forward. Also worse with deep breathing, coughing, and swallowing.
Q2: How does that pain pattern help you rule OUT an MI?
MI pain is not positional — no position change relieves crushing/pressure cardiac pain. If leaning forward helps, think pericarditis, not MI.
Q3: What does a pericardial friction rub sound like, and how do you best hear it?
Grating, scratchy, "leather-on-leather." Best heard with the diaphragm at the left sternal border with the client leaning forward.
Q4: What complication must you watch for as pericarditis worsens?
Cardiac tamponade — fluid fills the pericardial sac and compresses the heart (Beck's triad: JVD, muffled heart sounds, hypotension). See NG-178.