It presents as an inflammation of the thin sac or membrane that covers the outer surface of the heart called the pericardium.
Most cases are due to a viral infection that usually clears up within a few weeks.
The only treatment that is generally needed for pericarditis is anti-inflammatory medication.
There are some less common causes of pericarditis that may need other treatments.
Complications are rare, but can be very serious.
The pericardium is in charge of holding the heart in position, anchoring the heart in place, and preventing the heart from moving in the chest when the individual moves, making it work properly.
The pericardium has an inner and an outer layer, and there is a thin layer of “lubricating” fluid between the two layers.
This fluid keeps the layers from rubbing together when the heart moves to pump blood.
Causes of pericarditis
Generally, the cause of pericarditis is unknown, but it can include an infection (from viruses, bacteria, fungi, or parasites).
Infection with a virus is the most common cause.
Several different viruses can cause pericarditis, including Coxsackieviruses, echoviruses, influenza virus, adenovirus, mumps virus, human immunodeficiency virus, and viruses that cause hepatitis.
Other causes are rare and include:
- Infection with a germ (bacteria): This often causes pus to form between the inner and outer layers of the pericardium. The infection has usually already spread from nearby tissues (such as a heart infection) or from a wound infection after heart surgery. In rare cases, syphilis or fungi can infect the pericardium.
- TB infection: this is generally as part of a more widespread TB infection in the lungs and other parts of the body.
- Uremic pericarditis: This is inflammation caused by the build-up of waste products in the bloodstream in people with untreated kidney failure.
- Heart attack (myocardial infarction): Inflammation of the pericardium can occur if there is damage to nearby heart tissue, caused by a heart attack.
- After heart surgery: Swelling can occur a few days to a few weeks after open heart surgery.
- After an injury, for example after a stab wound or a severe blow to the chest.
- Inflammatory diseases that can affect various parts of the body can include inflammation of the pericardium, for example rheumatoid arthritis, scleroderma, polyarteritis nodosa, and systemic lupus erythematosus.
- Radiation therapies to treat breast cancers.
- Cancer that has spread to the pericardium from another part of the body (this is very rare).
In many cases, no cause can be found. This is called idiopathic pericarditis.
Many of these cases are probably caused by a viral infection that cannot be identified.
Symptoms of pericarditis
The common symptom in all types of pericarditis is chest pain that can be felt especially behind the breastbone, and sometimes under the collarbone, neck, and left shoulder.
It is a sharp, piercing pain in the center or left side of the chest that worsens when you breathe deeply, swallow, cough, or lie down. It usually improves if you sit or lean forward.
Symptoms very similar to a heart attack are felt.
Depending on the underlying cause of the pericarditis, there may also be various other symptoms such as:
- Weakness and tiredness
- Difficulty breathing.
- Pain when swallowing
- Palpitations or irregular heartbeat.
Diagnosis of pericarditis
A common sign of pericarditis is a pericardial rub. The doctor will listen to the heart.
Pericarditis can cause a rubbing or cracking sound, caused by rubbing against the inflamed lining of the pericardium.
This is known as “pericardial friction” and is best heard when the patient leans forward, holds their breath, and exhales.
You can also hear other sounds in the chest that are signs of fluid in the pericardium (pericardial effusion) or in the lungs (pleural effusion).
Depending on how severe the inflammation is, the doctor may also hear crackles in the lungs, which are signs of fluid in the space around the lungs or excess fluid in the pericardium.
Along with a complete medical history and physical exam, tests used to diagnose pericarditis may include:
Echocardiogram: This test uses sound waves to check the size and shape of your heart. Echo sound waves create an image on a screen when an ultrasound transducer passes over the skin over the heart.
The echocardiogram can show how well the heart is working and if fluid has built up around it and check for fluid or pericardium leaks around the heart.
An echo will show the classic signs of constrictive pericarditis, including a stiff or thick pericardium that constricts normal heart movement.
Electrocardiogram: This test records the strength and timing of the heart’s electrical activity. It shows abnormal rhythms and can sometimes detect heart muscle damage. Small sensors are attached to the skin to capture electrical activity to look for changes in the heart rate.
In about half of all patients with pericarditis, the heart rhythm goes through a sequence of four different patterns. Some patients do not have any changes, and if they do, they may be temporary.
Chest X-ray: An X-ray may be done to check the lungs, and any fluid present in the lungs. It can also be seen if the heart is enlarged.
Cardiac MRI: This is a test that takes detailed pictures of the heart. It can be used to look for thickening or other changes in the pericardium to check for extra fluid in the pericardium, pericardial swelling or thickening, or compression of the heart.
A contrast agent called gadolinium is used during this test which is highly specialized.
Cardiac CT scan: This type of X-ray takes a clear, detailed picture of the heart and pericardium. It can be used to rule out other causes of chest pain.
Look for calcium in the pericardium, fluid, inflammation, tumors, and disease in the areas around the heart. Iodine dye is used during the test to learn more about inflammation.
Cardiac catheterization – to obtain information about filling pressures in the heart. This is used to confirm a diagnosis of constrictive pericarditis.
Blood tests: Blood tests can be used to make sure the patient is not having a heart attack, to see how well their heart is working, to test the fluid in the pericardium, and to help find the cause of the pericarditis.
If you have pericarditis, it’s common for your sedimentation rate and ultra-sensitive C-reactive protein (inflammation markers) levels to be higher than normal. Other tests may be needed to detect autoimmune diseases such as lupus and rheumatoid arthritis .
Sharp pain in the chest and back of the shoulders and shortness of breath are two main clues that you may have pericarditis rather than a heart attack.
Treatment of pericarditis
The doctor will determine the best treatment based on the following:
- The age of the patient.
- The general state of health and medical history.
- The degree of the disease.
- Patient response to specific medications, procedures, or therapies.
- The length of time the condition is expected to last.
Treatment often involves medications, such as pain relievers, anti-inflammatories, or antibiotics.
If serious heart problems develop, treatment may include:
- The aspiration or removal of excess fluid around the heart.
Pericarditis can last 2 to 6 weeks and can come back.
In the treatment of viral or idiopathic pericarditis, anti-inflammatory drugs such as ibuprofen are given to relieve pain and reduce inflammation.
If the condition continues for more than 14 days, a drug called colchicine may also be given, which helps improve the outcome and reduces the chances that the swelling will return.
If the pain is severe and does not improve with ibuprofen and colchicine, steroid medications can be used to reduce inflammation.
The pain and inflammation usually resolve within a few weeks. Further treatment will depend on the cause of the pericarditis.
For example, anti-tuberculosis drugs for tuberculosis, antibiotics for infections with germs (such as bacteria), intensive dialysis for uremic pericarditis.
If the patient has chronic or recurrent pericarditis, he may need to take non-steroidal anti-inflammatory drugs or colchicine for several years, even if he feels fine.
A diuretic generally helps remove excess fluid caused by constrictive pericarditis.
Your doctor may also talk to the patient about treatment with steroids or other medications, such as azathioprine, IV human immunoglobulins, anakinra.
Most of the time, medications are the only necessary treatment for patients with pericarditis.
But, if fluid builds up in the pericardium and compresses the heart, you may need a procedure called pericardiocentesis.
In this procedure, a long, thin tube called a catheter is used to drain the extra fluid.
The catheter and a needle are guided to the pericardium with the use of echocardiography.
If the fluid cannot be drained with the needle, a surgical procedure called a pericardial window is performed.
In constrictive pericarditis, part of the pericardium may need to be removed. This type of surgery is called a pericardiectomy.
Surgery is not usually used as a treatment for patients with recurrent pericarditis, but your doctor may recommend it if other treatments are not successful.
Complications of pericarditis
When pericarditis appears, there is a small amount of fluid between the inner and outer layers of the pericardium.
Often when the pericardium becomes inflamed, the amount of fluid between these layers increases. This is called a pericardial effusion .
If the amount of fluid increases rapidly, the effusion can prevent the heart from working properly.
A small amount of fluid is not a problem and usually goes away when the swelling settles. However, sometimes a large amount of fluid builds up and can put pressure on the heart.
This can prevent the heart’s chambers from filling normally and prevent the heart from pumping blood properly.
This complication of pericarditis is called cardiac tamponade and is a serious emergency.
This cardiac tamponade is a life-threatening problem unless the fluid drains quickly.
Severe respiratory distress can develop rapidly in minutes to hours.
For treatment, a needle or thin tube (called a catheter) is placed into the chest to draw fluid in the pericardium and relieve pressure on the heart.
Sudden chest pain should always be treated as a medical emergency.
Symptoms of cardiac tamponade (a serious complication of pericarditis) include:
- Blurred vision
- Palpitations in the heart.
People with a history of pericarditis experiencing any of the above symptoms should seek medical attention immediately.
Chronic constrictive pericarditis occurs when scar tissue forms throughout the pericardium.
This is a rare condition but it can develop if the pericardium has been inflamed for a long time.
Scar tissue causes the pericardial sac to stiffen and not move properly.
Over time, the scar tissue tightens the heart and prevents it from working normally.
The only way to treat this is to remove the pericardium with a special type of heart surgery.
With both of the above complications, symptoms include shortness of breath that gets worse and worse.
Other symptoms of constrictive pericarditis can include swelling in the legs and ankles, as well as tiredness.
Most people with idiopathic or viral pericarditis make a full recovery within a few weeks, without complications.
However, in some cases, symptoms return “intermittently” for several months.
Pericarditis caused by a heart attack or injury usually sets in for only one to two weeks.
The outlook for other forms of pericarditis such as uremic, bacterial, tuberculous, among others, may vary depending on the severity of the underlying cause.