Pericarditis

Definition Pericarditis is a disorder caused by inflammation of the pericardium, which is the sac-like covering around the heart. 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 systemic diseases such as autoimmune disorders, rheumatic fever, tuberculosis, cancer, leukemia, kidney failure, HIV infection, AIDS, and hypothyroidism. Heart attack (see post-MI pericarditis) and myocarditis can cause pericarditis, as can radiation therapy to the chest and medications that suppress the immune system. Pericarditis can also be caused by injury (including surgery) or trauma to the chest, esophagus, or heart. Quite often the cause of pericarditis remains unknown, in which case it is called idiopathic pericarditis. Pericarditis most often affects men aged 20-50, usually following respiratory infections. In children, it is most commonly caused by adenovirus or coxsackie virus. Symptoms • Chest pain, caused by the inflamed pericardium rubbing against the heart. o Usually relieved by sitting up and leaning forward o Pleuritis type: a sharp, stabbing pain o May radiate to the neck, shoulder, back or abdomen o Often increases with deep breathing and lying flat, and may increase with coughing and swallowing Breathing difficulty when lying down Need to bend over or hold the chest while breathing Dry cough Ankle, feet and leg swelling (occasionally) Anxiety Fatigue Fever

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Signs and tests When listening to the heart with a stethoscope, the health care provider can hear a typical 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, or other signs of fluid in the space around the lungs (pleural effusion). If fluid has accumulated in the pericardial sac, it may show on: • • • • • Chest x-ray Echocardiogram Chest MRI scan Heart MRI or heart CT scan Radionuclide scanning

These tests show enlargement of the heart from fluid collection in the pericardium, and signs of inflammation. They may also show scarring and contracture of the pericardium (constrictive pericarditis). Other findings vary depending on the cause of pericarditis. An ECG is abnormal in 90% of patients with acute pericarditis. ECG changes generally evolve during the disease process, and they may mimic the ECG changes of a heart attack. To rule out heart attack, serial cardiac marker levels (CK -MB and troponin I) may be ordered. Other laboratory tests may include: • • • • • Blood culture CBC, may show increased WBC count C-reactive protein Erythrocyte sedimentation rate (ESR) Pericardiocentesis, with chemical analysis and pericardial fluid culture

Treatment The cause of pericarditis must be identified, if possible. In most types of pericarditis, it is necessary to treat the pain with analgesics (pain killers). The inflammation of the pericardium is treated with anti-inflammatory drugs(NSAIDS) such as aspirin and ibuprofen. Iin some cases, corticosteroids may be prescribed. Diuretics may be used to remove excess fluid accumulated in the pericardial sac. If the buildup of pericardial fluid 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 surgically in a minor procedure. Bacterial pericarditis must be treated with antibiotics. Fungal pericarditis is treated with antifungal agents. 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 resolve on their own to life-threatening cases 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.

Complications • • • Arrhythmias, such as atrial fibrillation. When pericarditis accompanies myocarditis, other arrhythmias may be present, such as supraventricular tachycardia (SVT) or complete heart block. Cardiac tamponade Constrictive pericarditis, where inflammation of the pericardial sac results in fibrosis and thickening of the pericardium with adhesions (sticky scars) between the pericardium and the heart. The pericardium creates a rigid "case" around the heart, which can severely limit the ability of the heart to fill with blood. Patients with constrictive pericarditis may develop heart failure, which responds poorly to treatment. Constrictive pericarditis must be differentiated from a chronic heart condition called restrictive cardiomyopathy, which produces symptoms and signs similar to constrictive pericarditis.

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.

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