What is Pericarditis?
The pericardium is like a double-layered, elastic bag that surrounds and protects your heart. It’s made up of an inner layer close to the heart, and an outer layer with lots of nerve connections. There’s a small space between these layers that normally has about a tablespoon or three of a watery fluid filling it. When the pericardium becomes inflamed, a condition known as ‘pericarditis’, it’s the most commonly seen issue with the pericardial bag.
Pericarditis varies over time and can be classified into differing forms: acute, new but slowly developing, long-standing, and recurring pericarditis. Recurring pericarditis happens in about 30% of cases. Sometimes, pericarditis can be associating with other health conditions involving the pericardium, like pericardial effusion or fluid buildup, cardiac tamponade, constrictive pericarditis, and effusive-constrictive pericarditis.
Frequently, inflammation in the pericardium can result in an accumulation of fluid within that protective bag, forming what is called a ‘pericardial effusion’. The type of fluid buildup may be watery, blood-tinged or pus-filled, all depending upon the cause of the problem. When there’s a significant pericardial fluid buildup or it collects too fast, this can cause problems. The fluid buildup can put pressure on the heart, causing it to fill up with blood slower. This particular situation is a syndrome named cardiac tamponade and is considered a medical emergency that needs immediate attention.
Moreover, after pericarditis, there may be a thickening of the pericardium which can lead to problems down the line, months or even years later. This could result in a condition called ‘constrictive pericarditis’. A type of pericarditis that has been more recently identified, called ‘effusive-constrictive pericarditis’, is when there is fluid buildup around the heart and certain symptoms are still seen even after the fluid is drained. This implies that the constriction is not fully dependent on the presence of fluid buildup.
These pericardial conditions might occur along with acute pericarditis, but they are not required for a pericarditis diagnosis. More information about these conditions would be discussed in detail further.
What Causes Pericarditis?
According to the 2015 European Society of Cardiology guidelines, acute pericarditis, a condition where the sac-like covering around the heart (pericardium) gets inflamed, can be broadly caused by infectious and non-infectious issues.
For infectious causes, viruses are the main culprits. These include coxsackieviruses, adenoviruses, parvovirus B19, HIV, and the flu, along with several herpes viruses. There are also bacterial reasons, which are less common in developed countries but remain a significant problem in the developing world. Tuberculosis, for instance, is prevalent in developing countries and is common in areas where it is endemic, especially amongst HIV-positive patients. Rarer still, pericarditis may result from other kinds of bacteria such as Coxiella burnetii, Meningococcus, Pneumococcus, Staphylococcus, and Streptococcus, which have caused severe pus-filled pericarditis (purulent cardiac tamponade) in some cases. Extremely rarely, this condition can be caused by fungi such as Histoplasma, Coccidioides, Candida, and Blastomyces or parasites like Echinococcus, and Toxoplasma. These are usually seen in people with weakened immune systems.
Non-infectious causes include diseases linked to cancer spread, connective tissue diseases (like lupus, rheumatoid arthritis, and Behçet’s disease), and metabolic issues (like Uremia, and myxedema, a severe form of hypothyroidism where the skin and tissues are swollen). Trauma or injury can also result in pericarditis either immediately after the event or cause a delayed inflammation.
Dressler Syndrome, also known as ‘late-post heart attack syndrome,’ can cause pericarditis. Here, inflammation occurs weeks after a heart attack due to an autoimmune response. This response is triggered by antibodies made against the patient’s own heart tissue. Nowadays, Dressler Syndrome is uncommon, thanks to improved heart attack management.
Some medications can cause pericarditis, but this is rare. Historically, drugs such as procainamide, hydralazine, and isoniazid were responsible for drug-induced lupus, a condition that can lead to pericarditis. More recently, certain cancer therapies known as checkpoint inhibitors have been linked to heart issues, including pericarditis. But these cases are expected to increase as these drugs are more widely used.
Other diseases like amyloidosis (an abnormal protein buildup in organs) and sarcoidosis (an inflammatory disease affecting various organs) should also be considered, especially when coupled with other symptoms. However, in up to 90% of cases, the cause isn’t clear, leading to a diagnosis of idiopathic acute pericarditis. This form is the most commonly seen in practice, and extensive testing usually isn’t needed unless there are clear symptoms pointing to a specific cause.
Risk Factors and Frequency for Pericarditis
Acute pericarditis, a common type of pericardial disease, is often the cause of chest pain. It is frequently seen in patients who have experienced trauma, patients with uremia, and those suffering from malignant diseases. This condition is more prevalent in men.
Signs and Symptoms of Pericarditis
Pericarditis, an inflammation of the lining around the heart, occurs in different forms based on duration. Here’s a brief summary:
- “Acute pericarditis” lasts less than 4-6 weeks
- “Incessant pericarditis” lasts more than 4-6 weeks but less than 3 months
- “Chronic pericarditis” lasts longer than 3 months
- “Recurrent pericarditis” is an episode that comes back after a symptom-free period of 4-6 weeks
Acute pericarditis is relatively rare, accounting for roughly 5% of non-heart attack related chest pain emergencies, and 0.1% of hospital admissions. Typical symptoms include chest pain that’s intense, gets worse with deep breathing, and gets better when sitting up and leaning forward. The pain may spread, potentially affecting the upper back muscles if the phrenic nerve, which passes through the lining around the heart, becomes inflamed. If there’s also inflammation of the heart muscle, the pain may be less specific, tied with symptoms of heart failure like shortness of breath.
There are a few ways doctors distinguish pericarditis from heart attack pain. Heart attack pain often gets worse with exercise or emotional stress, improves with rest or nitroglycerin treatment, doesn’t change with different positions or breathing patterns, and can’t be triggered with touch. However, it’s often tricky to tell the difference just based on symptoms, as heart attack pain can present in atypical ways. On the other hand, chest pain that’s linked to breathing, doesn’t improve when sitting up, and comes with respiratory symptoms like cough or mucus production, could indicate a lung condition. Lower chest pain that gets better when leaning forward, isn’t linked to breathing, and is related to eating, could point to a digestive issue like esophagitis or acute pancreatitis.
Testing for Pericarditis
If you’re experiencing chest pain, there could be several possible causes. These could include heart problems such as stable angina, acute coronary syndrome, or ischemia (which is reduced blood flow to the heart) caused by conditions such as aortic stenosis or hypertrophic cardiomyopathy. Other possibilities include aortic dissection, myocarditis, pleurisy caused by pulmonary embolism or pneumonia, costochondritis, esophageal spasm, peptic ulcer disease or pain referred from another organ like the gallbladder. In emergency situations, doctors will rule out conditions that might be life-threatening before considering acute pericarditis, especially if the diagnosis is uncertain.
In a checkup, your doctor may listen to your heart using a stethoscope. They are listening for a pericardial friction rub, which is a rasping, scratchy sound created by the layers of the pericardium (the sac holding your heart) rubbing together. This sound can be hard to hear and is only detected in about 35-85% of cases. If your doctor does hear it, though, it’s a strong indicator that you may have acute pericarditis. If the rub sound isn’t present, the doctor may still consider pericarditis if other symptoms point toward it.
Doctors often use an electrocardiogram (ECG) to assess heart health. In many cases of pericarditis, the ECG over time will show characteristic changes in four stages. These changes include the ST wave elevating in an atypical pattern and eventual normalization of the T wave. These changes can help differentiate between pericarditis and other conditions, like heart injury or an abnormal early repolarization pattern which is sometimes seen in healthy individuals.
To diagnose acute pericarditis, doctors consider factors like the description of your chest pain and whether they hear the pericardial friction rub when they listen to your heart. But often they also need to use other tests like laboratory studies, ECG and echocardiography (a type of ultrasound for the heart) to confirm the diagnosis. In some cases, scans like a CT or MRI may also be used.
Some clues can suggest what caused the pericarditis. Viral pericarditis might be associated with flu-like symptoms, while autoimmune conditions might have systemic signs like arthritis in the case of Rheumatoid Arthritis, skin and kidney problems in the case of lupus, or signs like confusion in the case of uremia. A recent heart injury or blunt trauma could also potentially lead to pericarditis symptoms, often occurring days or weeks after the event.
Treatment Options for Pericarditis
If you are suspected to have acute pericarditis, a health condition in which the thin layer of tissue around your heart is inflamed causing chest pain, a number of medical tests will be performed. These tests can include an electrocardiogram (ECG, a test that checks the heart’s electrical activity), an echocardiogram (an ultrasound of the heart), and a chest X-ray. Blood tests will also be done to measure inflammation and heart damage markers.
In some cases, additional tests might be conducted based on the potential cause of the pericarditis. These can include various blood tests, cultures, and screenings for infections like tuberculosis and HIV.
If further examination is needed, computed tomography (CT) or magnetic resonance imaging (MRI) can provide more detailed images of the heart. These advanced scanning techniques might show thickening of the pericardial layer, fluid accumulation, or potential abnormalities like tumors.
In emergency situations where a condition called cardiac tamponade occurs (where fluid builds up around the heart and affects its functioning), a procedure called pericardiocentesis might be performed. This involves removing the fluid from around the heart using a needle.
Pericardiocentesis can also be used for diagnosing cases where an infection is suspected. Fluid samples will be examined for the presence of bacteria, fungi, or tuberculosis. If the fluid is found to be infected, urgent treatment is initiated.
In areas where tuberculosis is common, treatment is started even before definitive diagnostic results are available. This involves taking a combination of four antibiotics for at least two months. If the treatment doesn’t show results in 4 to 8 weeks, a surgical procedure called pericardiectomy might be considered.
Initial treatment for acute pericarditis focuses on addressing the root cause. For instance, patients with uremia (high levels of waste products in the blood due to kidney problems) would undergo more frequent dialysis.
Most patients with acute pericarditis have no identifiable cause and can be treated just with medicines. Nonsteroidal anti-inflammatory drugs (NSAIDs) and a drug called colchicine are typically prescribed. For patients who don’t respond to these drugs, corticosteroids can be given under certain circumstances.
Lastly, specific acute pericarditis cases like those caused by medications or associated with kidney disease may carry an increased risk of heart complications. Therefore, doctors may advise stopping or modifying certain treatments like anticoagulants, medications that prevent blood clotting, if feasible.
What else can Pericarditis be?
Conditions such as:
- Pleurisy
- Pneumonia
- Acute myocardial infarction (heart attack)
- Bony pain (pain in bones)
- Costochondritis (inflammation of the chest wall)
- Angina (chest pain due to heart disease)
are some common health problems that doctors might consider when diagnosing other conditions.
What to expect with Pericarditis
Acute pericarditis, a condition where the thin layer around your heart becomes inflamed, generally has a very positive prognosis – most patients recover completely. However, around 30% of patients who are not treated with a medicine called colchicine could experience recurrent pericarditis, where the condition returns.
Constrictive pericarditis, a more serious form of the condition where the pericardium becomes thick and rigid, rarely follows acute pericarditis – it happens in less than 1% of cases. But, if the inflammation is caused by serious conditions like severe bacteria or tuberculosis, the risk of the pericardium becoming constricted may increase to as much as 30%.
Cardiac tamponade, a dangerous complication where fluid builds up in the pericardium, is rarely seen in patients with simple acute pericarditis. However, it is encountered more often in patients whose pericarditis is caused by more serious conditions, such as cancer or infections.
