Pericarditis

Definition

Pericarditis is a condition in which the sac-like covering around the heart (pericardium) becomes inflamed.

Alternative Names

Causes, incidence, and risk factors

The cause of pericarditis is often unknown or unproven, but is often the result of an infection such as:

• Viral infections that cause a chest cold or pneumonia, such as the echovirus or coxsackie virus (which are common in children), as well as influenza
• Infections with bacteria (much less common)
• Some fungal infections (even more rare)

In addition, pericarditis may be seen with diseases such as:

• Cancer (including leukemia)
• Disorders in which the immune system attacks healthy body tissue by mistake
• HIV infection and AIDS
• Underactive thyroid gland
• Kidney failure
• Rheumatic fever
• Tuberculosis (TB)

Other causes include:

• Heart attack
• Heart surgery or trauma to the chest, esophagus, or heart
• Certain medications, such as procainamide, hydralazine, phenytoin, isoniazid, and some drugs used to treat cancer or suppress the immune system
• Swelling or inflammation of the heart muscle
• Radiation therapy to the chest

Often the cause of pericarditis is unknown. Pericarditis most often affects men ages 20 - 50.

Symptoms

Chest pain is almost always present. The pain:

• May be felt in the neck, shoulder, back, or abdomen
• Often increases with deep breathing and lying flat, and may increase with coughing and swallowing
• Can be a sharp, stabbing pain
• Is often relieved by sitting up and leaning or bending forward

You may have fever, chills, or sweating if the condition is caused by an infection.

Other symptoms include:

• Ankle, feet, and leg swelling (occasionally)
• Anxiety
• Breathing difficulty when lying down     
• Dry cough
• Fatigue     

Signs and tests

When listening to the heart with a stethoscope, the health care provider can hear a sound called a pericardial rub. The heart sounds may be muffled or distant. There may be other signs of fluid in the pericardium (pericardial effusion).

If the disorder is severe, there may be:

• Crackles in the lungs
• Decreased breath sounds
• Other signs of fluid in the space around the lungs (pleural effusion)

The following imaging tests may be done to check the heart and the tissue layer around it (pericardium):

• Chest MRI scan
• Chest x-ray
• Echocardiogram
• Electrocardiogram
• Heart MRI or heart CT scan
• Radionuclide scanning

To look for heart muscle damage, the health care provider may order a troponin I test. Other laboratory tests may include:

• Antinuclear antibody (ANA)
• Blood culture
• CBC
• C-reactive protein
• Erythrocyte sedimentation rate (ESR)
• HIV test
• Rheumatoid factor
• Tuberculin skin test

Treatment

The cause of pericarditis must be identified, if possible.

High doses of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are often given. These medicines will decrease your pain and reduce the swelling or inflammation in the sac around your heart.

A medicine called colchicine may be added, especially if pericarditis does not go away after 1 to 2 weeks or it comes back weeks or months later.

If the cause of pericarditis is an infection:

• Antibiotics will be used for bacterial infections
• Antifungal medications will be used for fungal pericarditis

Other medicines that may be used are:

• Corticosteroids such as prednisone (in some patients)
• "Water pills" (diuretics) to remove excess fluid

If the buildup of fluid makes the heart function poorly, treatment may include:

• Draining the fluid from the sac. This procedure, called pericardiocentesis, may be done using an echocardiography-guided needle.
• Cutting a small hole (window) in the pericardium (subxiphoid pericardiotomy) to allow the infected fluid to drain into the abdominal cavity

If the pericarditis is chronic, recurrent, or causes scarring or tightening of the tissue around the heart, cutting or removing part of the pericardium may be needed. This surgery is called a pericardiectomy.

Support Groups

Expectations (prognosis)

Pericarditis can range from mild cases that get better on their own to life-threatening cases. The condition can be complicated by fluid buildup around the heart and poor heart function.

The outcome is good if the disorder is treated right away. Most people recover in 2 weeks to 3 months. However, pericarditis may come back. This is called recurrent, or chronic if symptoms or episodes continue.

Scarring and thickening of the sac-like covering and the heart muscle may occur in severe cases. This is called constrictive pericarditis, and it can cause long-term problems similar to those of heart failure.

Complications

Calling your health care provider

Call your health care provider if you have symptoms of pericarditis. This disorder is usually not life threatening, but it can be if not treated.

Prevention

Many cases are not preventable.

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References

LeWinter MM, Tischler MD. Pericardial diseases. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 75.