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ULY CLINIC

14 Septemba 2025, 09:42:25

Pericardial friction rub

A pericardial friction rub is a scratching, grating, or crunching sound produced when two inflamed layers of the pericardium slide over each other. It ranges from faint to loud and is best heard along the lower left sternal border during deep inspiration. This sign indicates pericarditis, which may result from infections, cardiac or renal disorders, postpericardiotomy syndrome, or certain drugs.

History and Physical examination

History

Cardiac history: Recent myocardial infarction, cardiac surgery, or prior pericarditis.
Rheumatic/autoimmune disorders: Rheumatoid arthritis, systemic lupus erythematosus.
Renal disease or infection history.
Chest pain: Character, location, aggravating and relieving factors.

Physical Examination

Vital signs: Hypotension, tachycardia, irregular pulse, tachypnea, fever.
Inspection: Jugular vein distention, peripheral edema, ascites, hepatomegaly.
Auscultation: Listen for rub along lower left sternal border; compare with pleural rubs and murmurs.

Patient position

A pericardial friction rub is usually loudest during deep inspiration and is best heard when the patient leans forward. This positioning helps distinguish it from a murmur, which varies in timing and duration with respiration and posture.

Distinguishing from Murmurs

Feature	Pericardial Friction Rub	Murmur
Depth	Superficial	Deeper
Radiation	Usually does not radiate	Often radiates
Variation	Varies with respiration	Usually constant

Tip: The classic rub is triphasic and linked to the cardiac cycle:

Presystolic – reflects atrial systole (before S1)
Systolic – reflects ventricular systole (between S1 and S2)
Early diastolic – reflects ventricular diastole (after S2)

Variants include diphasic or monophasic rubs, depending on which components are audible.

Medical causes

Causes of pericardial friction rub

Condition	Clinical Features	Other Important Information
Acute Pericarditis	Sharp precordial/retrosternal chest pain, radiates to left shoulder/neck/back; worsens with deep inspiration, coughing, lying flat; relieved by sitting forward; fever, dyspnea, tachycardia, arrhythmias	Hallmark cause of pericardial friction rub; may be viral, bacterial, autoimmune, or post-MI (Dressler syndrome)
Chronic Constrictive Pericarditis	Gradual onset rub; peripheral edema, ascites, hepatomegaly, Kussmaul’s sign (JVD on inspiration), dyspnea, orthopnea, paradoxical pulse, chest pain	Decreased cardiac filling/output; may develop over months to years
Post-Cardiac Surgery / Post-Pericardiotomy Syndrome	Fever, malaise, pleuritic chest pain, pericardial friction rub; may occur days to weeks after surgery	Autoimmune inflammatory reaction against pericardial tissue
Uremic Pericarditis	Rub may occur in patients with advanced renal failure; chest pain often mild; may have pericardial effusion	Usually seen in patients with BUN >60 mg/dL; dialysis may relieve symptoms
Infectious Pericarditis	Fever, chills, malaise; rub associated with bacterial, viral, or fungal infections	May lead to purulent pericarditis or cardiac tamponade in severe bacterial cases
Myocardial Infarction (Early Post-MI Pericarditis / Dressler Syndrome)	Friction rub may appear days after MI; pleuritic chest pain, fever; rub often transient	Dressler syndrome is autoimmune, occurs 2–6 weeks post-MI; may include pericardial effusion
Trauma	Chest wall trauma may cause localized pericardial inflammation and rub; may be associated with hemopericardium	Usually monophasic; evaluate for cardiac contusion or tamponade
Drug-Induced Pericarditis	Associated with drugs such as procainamide, hydralazine, certain chemotherapeutics	Discontinuation may resolve inflammation; monitor for effusion
Radiation-Induced Pericarditis	History of chest radiotherapy; can occur months to years post-exposure	Can progress to constrictive pericarditis; monitor cardiac function
Autoimmune Disorders	Rheumatoid arthritis, SLE, systemic vasculitis	May present with systemic symptoms, arthralgia, and fever; pericardial effusion is common
Neoplastic Pericarditis	Rub may occur with infiltration of pericardium by tumors (lung, breast, lymphoma)	Often associated with pericardial effusion, tamponade; may require pericardiocentesis or biopsy

Special considerations

Monitor for cardiac tamponade if rub disappears: pallor, hypotension, tachycardia, tachypnea, paradoxical pulse, jugular vein distention.
Prepare for pericardiocentesis if tamponade develops.
Manage underlying cause: rest, anti-inflammatories, antiarrhythmics, diuretics, antimicrobials; consider pericardiectomy if chronic.

Patient counseling

Explain underlying disorder and treatment options.
Teach strategies to minimize symptoms (positioning, rest, medication adherence).

Pediatric pointers

Bacterial pericarditis may occur before age 6.
Pericardial friction rub can follow surgery for congenital heart anomalies but may vanish without full pericarditis.
Other more reliable signs: fever, tachycardia, dyspnea, chest pain, jugular vein distention, hepatomegaly.

References

Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary care: A collaborative practice. St. Louis (MO): Mosby Elsevier; 2008. p. 444–447.
McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The biologic basis for disease in adults and children. Maryland Heights (MO): Mosby Elsevier; 2010.
Sommers MS, Brunner LS. Pocket diseases. Philadelphia (PA): F.A. Davis; 2012.