Pericarditis

Definition

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

See also: Bacterial pericarditis

Causes, incidence, and risk factors

Pericarditis is usually a complication of viral infections, most commonly echovirus or coxsackie virus. Less frequently, it is caused by influenza or HIV infection.

Infections with bacteria can lead to bacterial pericarditis (also called purulent pericarditis). Some fungal infections can also produce pericarditis.

In addition, pericarditis can be associated with diseases such as:

• Autoimmune disorders
• Cancer (including leukemia)
• HIV infection and AIDS
• Hypothyroidism
• Kidney failure
• Rheumatic fever
• Tuberculosis

Other causes include:

• Heart attack (see post-MI pericarditis)
• Injury (including surgery) or trauma to the chest, esophagus, or heart
• Medications that suppress the immune system
• Myocarditis
• Radiation therapy to the chest

Often the cause of pericarditis remains unknown. In this case, the condition is called idiopathic pericarditis.

Pericarditis most often affects men aged 20 - 50. It usually follows respiratory infections. In children, it is most commonly caused by adenovirus or coxsackie virus.

Symptoms

• Ankle, feet, and leg swelling (occasionally)
• Anxiety
• Breathing difficulty when lying down
• Chest pain, caused by the inflamed pericardium rubbing against the heart
  • May radiate to the neck, shoulder, back, or abdomen
  • Often increases with deep breathing and lying flat, and may increase with coughing and swallowing
  • Pleuritis type: a sharp, stabbing pain
  • Usually relieved by sitting up and leaning forward
• Dry cough
• Fatigue
• Fever
• Need to bend over or hold the chest while breathing

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)

If fluid has built up in the pericardial sac, it may show on:

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

These tests show:

• Enlargement of the heart
• Signs of inflammation
• Scarring and contracture of the pericardium (constrictive pericarditis)

Other findings vary depending on the cause of pericarditis.

To rule out heart attack, the health care provider may order serial cardiac marker levels (CPK-MB and troponin I). Other laboratory tests may include:

• Blood culture
• CBC
• C-reactive protein
• Erythrocyte sedimentation rate (ESR)
• HIV serology
• Pericardiocentesis, with chemical analysis and pericardial fluid culture
• Tuberculin skin test

Treatment

The cause of pericarditis must be identified, if possible.

Medications include:

• Analgesics for pain
• Antibiotics for bacterial pericarditis
• Antifungal medications for fungal pericarditis
• Aspirin or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen for inflammation of the pericardium
• Corticosteroids such as prednisone
• Colchicine
• Diuretics to remove excess fluid in the pericardial sac

If the buildup of fluid in the pericardium makes the heart function poorly or produces cardiac tamponade, it is necessary to drain the fluid from the sac. This procedure, called pericardiocentesis, may be done using an echocardiography-guided needle or minor surgery.

If the pericarditis is chronic, recurrent, or causes constrictive pericarditis, cutting or removing part of the pericardium may be recommended.

Expectations (prognosis)

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

The outcome is good if the disorder is treated promptly. Most people recover in 2 weeks to 3 months. However, pericarditis may come back.

Complications

• Arrhythmias
• Cardiac tamponade
• Constrictive pericarditis, which may develop into heart failure

Calling your health care provider

Call your health care provider if you experience the symptoms of pericarditis. This disorder can be life-threatening if untreated.

Prevention

Many cases are not preventable.

References

LeWinter MM. Pericardial diseases. In: Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 70.