What is pericarditis?

Pericarditis is an inflammation of the pericardium, which is the sac that surrounds the heart. The pericardium normally functions to protect the heart, and reduce friction between the heart and surrounding organs.

Pericarditis may be accompanied by pericardial effusion, which is fluid accumulation in the pericardial sac.

If a large amount of fluid accumulates in the pericardium, it may squeeze or constrict the heart; this is called cardiac tamponade.

Cardiac tamponade is a serious condition that can be life-threatening if not recognised and treated promptly.

Pericarditis accounts for five per cent of Emergency Room visits for chest pain not due to a heart attack, making it a fairly common ER diagnosis. Acute pericarditis is more common in men than in women, and in adults than in children.

Pericarditis causes

• Any bug can infect the pericardium though the majority of cases are caused by a viral infection.

• Cancer is the most common cause of pericardial effusion with tamponade in developed countries. It occurs when a cancer spreads to the heart, most commonly breast or lung cancer, or with lymphomas.

• Radiation therapy for cancers can cause a reactive pericarditis.

• Trauma to the chest may be blunt, as with a steering wheel injury, or sharp, as with a bullet or knife wound.

• A myocardial infarction (heart attack) can be complicated by a reactive pericarditis.

• Drugs, kidney failure, rheumatic diseases (like lupus or rheumatoid arthritis), and gastrointestinal conditions (ulcerative colitis or Crohn) account for a fair percentage of pericarditis cases.

• An unknown cause, so-called “idiopathic”, is the most common scenario.

Pericarditis symptoms

The most common sign of acute pericarditis is chest pain, usually worsened when taking a deep breath.

It usually begins suddenly, is often sharp, and is felt over the front of the chest. The pain may decrease in intensity when sitting up and may radiate around the shoulder to the upper back. Some people with pericarditis develop a fever.

Pericarditis diagnosis

Physical examination: In people with pericarditis, there is often an abnormal heart sound called a friction rub. This sound is created when the inflamed pericardial layers rub against each other.

Electrocardiogram: Pericarditis and pericardial effusion produce distinctive patterns on an electrocardiogram.

Echocardiogram: An ultrasound examination of the heart is generally recommended since it is a sensitive test for the detection of pericardial effusion.

If a pericardial effusion is present, echocardiography can also help determine whether the effusion is limiting the filling of the heart (ie causing cardiac tamponade).

However, not having a pericardial effusion on the echocardiogram does not exclude the possibility of pericarditis.

Blood test: Most people with pericarditis also have an elevated blood level of an inflammatory substance called C-reactive protein.

CRP is especially important to confirm the suspicion of pericarditis and to monitor the inflammatory disease process and its response to therapy.

Pericarditis treatment

The goals of treatment for pericarditis include relief of pain, and resolution of inflammation and effusion.

Pain treatment begins with aspirin, or a nonsteroidal anti-inflammatory drug. It may be recommended that patients take another medication, colchicine, as well. In several studies, colchicine was found to improve symptoms and reduce the risk of pericarditis recurring. If these medications are not helpful or cannot be tolerated, a steroid (eg prednisone) may be recommended. In most cases, the steroid dose is maintained for several days and then reduced very slowly, over a period of weeks, to reduce the risk of recurrent pericarditis.

When the cause of pericarditis is identified, treatment is aimed at the underlying condition. As an example, pericarditis that is caused by a bacterial infection would be treated with one or more antibiotics. However, viral pericarditis does not require any specific antiviral treatment, and is managed by empiric anti-inflammatory therapies.

Pericardiocentesis is the medical term for removal of fluid from the pericardium with a thin needle. It may be recommended for some patients with pericardial effusion or cardiac tamponade. The procedure may be useful both as a treatment and as a tool to determine the cause of pericarditis.

Recurrent pericarditis

Approximately 15 to 30 per cent of people with acute pericarditis have either recurrent or persistent disease, frequently with pericardial fluid. While the same above treatment applies for recurring cases, other medications may be offered, or a surgical procedure called a pericardial window might be needed. In resistant cases, stripping part of, or the whole pericardial sac, can be a last resort.

Joe Yammine is a cardiologist at Bermuda Hospitals Board. He trained at the State University of New York, Brown University and Brigham and Women’s Hospital. He holds five American Board certifications. He was in academic practice between 2007 and 2014, when he joined BHB. During his career in the US, he was awarded multiple teaching and patients’ care recognition awards. The information herein is not intended as medical advice nor as a substitute for professional medical opinion. Always seek the advice of your physician. You should never delay seeking medical advice, disregard medical advice or discontinue treatment because of any information in this article.