Pericarditis

What are the symptoms of pericarditis?

Most people will develop sudden onset of a sharp and stabbing chest pain that remains fairly constant throughout the day and has no relation to activity. Certain positions like lying down or lying on one’s left side can make the pain worse as it stretches the inflamed pericardium more. Most people get relief from sitting or leaning forward. In addition, patients can develop a cough and will have pain with coughing, swallowing or taking deep breaths.

Other symptoms can include:

• Fever
• Palpitations
• Difficulty breathing
• Swelling of the lower legs, ankles and feet

In more severe cases, the inflamed pericardium can also lead to significant fluid build-up between the two layers of the pericardium, known as a pericardial effusion. This can limit the ability of the heart to fill with blood properly, resulting in very significant shortness of breath, high heart rates and low blood pressure. This is called cardiac tamponade, a medical emergency which needs rapid removal of that fluid.

What are the causes of pericarditis?

• Idiopathic: In most cases (80-90% of the time) there is no clear cause for the pericarditis.
• Infectious: When the pericarditis occurs after certain infections, which could be bacterial (tuberculosis), viral (flu or COVID), or a fungal infection.
• Autoimmune: When pericarditis is caused by an autoimmune disease such as lupus, scleroderma or rheumatoid arthritis.
• Complication following certain cardiac procedures: Such as open-heart surgery, cardiac catheterization or radiofrequency ablation.
• Certain medications: Such as hydralazine, phenytoin, isoniazid and some medications used to treat cancer or suppress the immune system.

How is pericarditis diagnosed?

Diagnosis of pericarditis is often based on a combination of different symptoms and testing results.

• By symptoms: Sharp and stabbing pain in the chest that feels worse when lying down and feels better with sitting up.
• By exam: Sometimes your physician can hear a distinct sound when listening to the heart known as a “pericardial rub” (the two layers of the membrane rubbing together).
• By electrocardiogram (ECG or EKG): There can be some characteristic findings on the electrocardiogram that are present during an acute episode of pericarditis and resolve over time.
• Laboratory testing: Certain markers of inflammation (C-reactive protein and ESR levels) can be elevated in acute episodes and are sometimes followed over time to evaluate for resolution of the episode/efficacy of certain medications.
• By echocardiogram: This is a good test to evaluate how much fluid is present around the heart. It can also show signs of chronic constriction when the pericardium has become thick and scarred and interferes with how well the heart fills with blood.
• By Cardiac MRI: This is not typically checked for a first-time episode of pericarditis but can be a useful way to evaluate if there is evidence of chronic inflammation of the pericardium in recurrent or chronic pericarditis cases.

How is pericarditis treated?

For most cases of acute pericarditis, oral non-steroidal anti-inflammatory medications (such as ibuprofen or high-dose aspirin) should provide patients with quick pain relief by decreasing the inflammation of the pericardium.

To decrease the chance of having a recurrence of pericarditis weeks or months later, most patients should also be prescribed another anti-inflammatory medication, called colchicine.

In very rare cases, a short course of steroids (prednisone) can be used, especially when patients are unable to take non-steroidal anti-inflammatory medications due to kidney disease or stomach ulcers.

For patients with chronic pericarditis or those who have had multiple flares of recurrent pericarditis despite good treatment, there are now newer medications available to improve quality of life. These newer medications are immunosuppressant medications that target certain inflammation receptors in the pericardium and block them (interleukin-1 blockers), thereby reducing the inflammation of the pericardium.

If there is evidence of significant fluid build-up around the heart, this needs to be removed by placing a narrow, flexible catheter into the pericardial space and draining the fluid, sometimes leaving the drain in for a few days to ensure all the fluid has been removed.

If the pericarditis is felt to be the result of an autoimmune disorder, patients will require treatment for their autoimmune disease as well.

In rare cases where the pericardium has become so scarred and thick that it is causing permanent constriction around the heart, patients will need to undergo a surgical procedure where the pericardium is removed (pericardiectomy).

What is the long term outlook for pericarditis?

For most patients with an acute episode of pericarditis, the outlook is good, and patients are able to return to their normal daily activities within several weeks without any long-term consequences. However, for about 1/3 of patients who have had one acute episode, there will be recurrent episodes or flares. For many of these patients, this can seriously affect their quality of life. In part, this is due to the chronic chest pain, but for many patients it is also living with the unpredictability of when another flare may strike. With adequate treatment, however, this can be minimized.