Acute Pericarditis

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.

What causes pericarditis?

Pericarditis has many causes, including the following:

  • Viral infection: This is probably the commonest cause that is seen, but the specific type of virus is not always identified. Typically, the pericarditis symptoms are preceded by viral-type symptoms such as runny nose, sore throat, headache, fever, aches and pains. The symptoms of pericarditis can develop days to weeks after the viral symptoms. Sometimes there are no preceding viral symptoms.
  • Other infections: Any infectious organism can infect the pericardium such as bacteria or even fungal infections. These are quite rare though. They often result in very severe symptoms and people require urgent hospital treatment with antibiotics.
  • Unknown cause: In many cases, the cause of pericarditis cannot be determined. It is not always necessary to know the cause, especially if the condition improves with treatment.
  • Rheumatic diseases: A number of the auto-immune diseases such as systemic lupus erythematosus (SLE or “lupus”), scleroderma and rheumatoid arthritis may cause pericarditis. In these cases, there is no infection and the treatment is directed at the underlying auto-immune condition.
  • Radiation: Prior radiation to the chest is an important cause of pericardial disease. In most of these cases, people received the radiation several years back, usually as treatment for cancer.
  • Drugs and toxins: A number of medications can cause pericarditis.
  • Metabolic disorders: The major cause of metabolic-related pericarditis is kidney failure.
  • Gastrointestinal diseases: Pericarditis may occur in patients with inflammatory bowel disease (ulcerative colitis or Crohn’s disease).

What are the symptoms of pericarditis?

The most common symptom of acute pericarditis is chest pain. It often begins fairly suddenly, is sharp, and is felt over the front of the chest. It has the characteristic quality of becoming more painful when taking a deep breath or during coughing. It may also be worse when lying down and can also cause pain when swallowing.

Other symptoms may include hot and cold feelings suggestive of a fever, viral-type symptoms including runny nose, sore throat, headache and aches and pains. People may also notice shortness of breath, especially if fluid has accumulated in the pericardium as a result of the pericarditis.

How is pericarditis diagnosed?

Pericarditis is diagnosed based upon the way the person describes the onset and nature of his/her symptoms, a physical examination and laboratory and imaging tests.

During a physical examination, the doctor will measure your heart rate, blood pressure and temperature. He/she will also listen to the heart with a stethoscope. In people with pericarditis, there is often an abnormal heart sound called a pericardial rub. This sound is created when the inflamed pericardial layers rub against each other.

A number of tests may then be performed. An electrocardiogram (ECG) can often show a distinctive pattern that confirms a diagnosis of pericarditis. A chest X-ray may show enlargement of the heart. Blood tests are done to look for signs of inflammation and occasionally to check for any bacteria in the blood.

A heart ultrasound (echocardiogram) examination of the heart is also generally performed. While the echocardiogram may be entirely normal in cases of pericarditis, it is the best test to look for any accumulation of fluid in the pericardium. It is also the best way to see if any accumulated fluid is placing undue pressure on the heart, which would then require drainage.

How is pericarditis treated?

The goals of treatment for pericarditis include relief of pain and resolution of the inflammation. If fluid has built up in the pericardium to the extent that it is putting pressure on the heart (tamponade), drainage may be required. Specific treatment for the cause of pericarditis may also be required.

Some people will be evaluated in a clinic or hospital and then treated at home while others may require initial treatment in a hospital. The need for hospital treatment is more likely when symptoms are severe, there is uncertainty about the diagnosis, several tests are required, or there is fluid accumulation the pericardium.

Pain relief is very important and in most cases, treatment begins with aspirin or a nonsteroidal antiinflammatory drug (NSAID). If pain does not improve within one week, further evaluation and treatment are necessary.

Another medication, colchicine, may be recommended in addition to the NSAID. In several studies, colchicine was found to improve symptoms and reduce the risk of a future (recurrent) episode of pericarditis.

If these medications are not helpful or cannot be tolerated, a steroid (eg, prednisolone) 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 may be 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 almost always resolves without antiviral treatment.

If fluid has accumulated in the pericardium as a result of the pericarditis and puts undue pressure on the heart, effectively squashing it and preventing it form pumping properly (known as cardiac tamponade), urgent drainage of the fluid is usually required. This is done with a small drain tube placed through the skin and chest wall into the pericardium itself, or occasionally by a small surgical operation.

Can pericarditis recur?

In a minority of cases (approximately 15-30%), pericarditis can take a course where it either recurs or remains persistent. The risk of this is reduced if people take colchicine with the initial episode and in those with a known cause of pericarditis. Treatment of recurrent pericarditis usually includes aspirin or a nonsteroidal antiinflammatory drug (NSAID) and/or colchicine. In addition, further evaluation and treatment of the underlying cause is appropriate. Treatment with a steroid (eg, prednisolone) may be recommended if there is no response to these initial therapies. When steroids are used, the goal is to use the lowest possible dose for the shortest possible time. The steroid is slowly tapered to reduce the risk of a recurrence. In rare cases, surgery may be required to remove part or most of the pericardium from around the heart.