Pericarditis

What is it?

Pericarditis is an inflammation of the pericardium, the saclike membrane that surrounds the heart. Pericarditis can be triggered by a number of different medical conditions. Often the exact cause cannot be identified. Doctors call this idiopathic pericarditis.

In many people with pericarditis, the initial trigger is a viral infection. However, the inflammation may not be a direct result of the infection. Instead, the virus may stimulate the immune system to attack and inflame the pericardium.

Other medical conditions associated with pericarditis include:

• An autoimmune disease. Several diseases are caused by the immune system attacking our own organs, including the pericardium. Examples include systemic lupus erythematosus (SLE) and rheumatoid arthritis.
• A bacterial infection. A serious infection can spread directly into the pericardium from a heart valve (endocarditis), the lung or a tear in the esophagus. Also a blood infection, especially staph, can get into the lining around the heart.
• Tuberculosis. Tuberculous pericarditis can occur as part of an active tuberculosis infection.
• Uremia. Uremic pericarditis can occur in people with uremia, an accumulation of urea and other waste products in the blood caused by kidney failure.
• Heart attack (myocardial infarction). Sometimes a major heart attack will inflame the pericardium next to the area of the heart that is damaged.
• Cardiac injury. As in heart attack, heart damage caused by trauma (a stab wound or severe blow to the chest) or cardiac surgery also can trigger pericarditis.
• Dressler's syndrome (also called post cardiac surgery or post cardiac injury syndrome). The pericarditis of Dressler's syndrome can begin within a couple weeks or up to many months after open heart surgery, heart trauma or a heart attack. It is thought that with this syndrome, prior heart injury stimulates the immune system to attack and inflame the pericardium.

Other rare causes of pericarditis include radiation therapy to treat cancers in the chest, cancer in the chest area, a fungal infection or a parasitic infection.

Pericarditis can be:

• acute -- New onset of an inflamed pericardium causing symptoms over several hours to a couple weeks
• chronic -- Persistent inflammation of the pericardium over many weeks and sometimes months
• recurrent -- Repeated episodes of acute pericarditis. In between, episodes there are no symptoms and no obvious inflammation of the pericardium.

The inflammation of pericarditis usually causes fluid to weep into the pericardial sac. This is known as a pericardial effusion. If the pericardial effusion is large enough, it can interfere with the heart's ability to fill normally and to pump blood, a condition called cardiac tamponade.

Sometimes, pericarditis leads to scarring of the lining around the heart. The inflamed pericardium thicken can thicken and contract around the heart, interfering with heart function. This condition is called constrictive pericarditis.

Symptoms

The classic symptoms of acute pericarditis are chest pain and fever. This chest pain can be either brief and sharp or steady and constricting. It is usually under the breastbone, but it also can spread to the neck or shoulders. In many patients, chest pain becomes more severe if they take a deep breath, swallow, cough, or lie down. Sitting up or leaning forward may relieve the pain.

Patients with cardiac tamponade can have low blood pressure and shortness of breath. Patients with constrictive pericarditis also can have breathing difficulties, together with edema (swelling) of the ankles, legs and abdomen.

Diagnosis

Your doctor will review your medical history. He or she will specifically want to know if you have:

• had a recent viral infection
• an autoimmune disease
• had a heart attack recently
• a history of chest trauma, including surgery
• had tuberculosis and/or tuberculosis exposure
• kidney disease.

Your doctor also will ask you to describe your chest pain, including its location, what triggers it (cough, swallowing, deep breath), how long it lasts and what relieves it. He or she will ask about other symptoms especially fever, joint aches and any new rash.

The nurse or medical assistant will take temperature, and measure your heart rate and blood pressure. The doctor's exam will focus on the heart. Your doctor will use a stethoscope to listen for a characteristic grating, leathery sound that can appear in patients with pericarditis. This sound is called a pericardial friction rub.

If your doctor is concerned that the chest pain is related to a heart attack, he or she will likely call an ambulance to take you to the hospital.

Tests commonly used to help diagnose pericarditis include:

• an electrocardiogram (EKG)
• a chest X-ray
• an echocardiogram, a painless scan that uses sound waves to delineate structures in and around the heart
• blood tests for inflammation.

If a pericardial effusion has developed, a sample of the fluid may be removed (aspirated) from around your heart with a sterile needle and examined in a laboratory. Also, depending on the suspected cause of the pericarditis, you may need a skin or blood test for tuberculosis or additional blood testing to look for signs of infection, heart attack, or autoimmune disease.

Expected duration

The symptoms of acute pericarditis usually improve within a few days of starting treatment. Acute pericarditis most often resolves completely without damage to the heart or the pericardium.

Pericarditis in people with autoimmune disease is more likely to recur and/or persist.

Prevention

Because pericarditis can be the result of so many very different illnesses, there are no routine guidelines to prevent the condition. You can help prevent pericarditis caused by infections by practicing good hygiene, especially washing your hands often, and by keeping up with recommended immunizations.

To prevent pericarditis caused by heart attack, you can reduce your risk of coronary artery disease by not smoking, eating a healthy diet, exercising regularly, lowering LDL cholesterol and controlling blood pressure.

To reduce your risk of trauma-related pericarditis, you should wear a seat belt whenever you drive and wear appropriate chest-protecting equipment when you play contact sports.

Treatment

The treatment of acute pericarditis depends on the cause. You will be told to rest and to take aspirin or an anti-inflammatory drug.

For viral and idiopathic acute pericarditis, doctors often prescribe a combination of colchicine and a non-steroidal anti-inflammatory drug (NSAID), such as naproxen (Naprosyn, Aleve, generic versions) or ibuprofen (Motrin, Advil, generic versions). The NSAID dose is usually higher than the dose indicated on the over-the-counter preparations.

Your doctor may decide to treat with you a corticosteroid, such as prednisone, especially if you have a known autoimmune disease.

Patients with tuberculous pericarditis will need anti-tuberculosis medication.

Those with a bacterial infection will need strong antibiotics and removal of any infected fluid around the heart.

Patients with uremic pericarditis caused by kidney failure will need hemodialysis, a mechanical procedure to clean the blood.

If you have cardiac tamponade, excess fluid around your heart will be withdrawn with a sterile needle in a procedure called pericardiocentesis.

When constrictive pericarditis interferes with heart function, the thickened pericardium may be removed surgically in a procedure called a pericardiectomy.

For patients with idiopathic or recurrent pericarditis, daily colchicine can reduce the frequency and severity of future attacks.

When to call a professional

Always seek medical attention for new and unexplained chest pain.

Prognosis

Most people with acute pericarditis recover within 2 to 4 weeks. Recurrence of acute pericarditis occurs in about 20 percent of the people who have unexplained pericarditis.

Pericarditis in people with autoimmune disease may come and go, depending on course of the underlying medical illness.

Additional info

American Heart Association (AHA)
https://www.heart.org

National Heart, Lung and Blood Institute (NHLBI)
https://www.nhlbi.nih.gov/