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Pericarditis

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Updated October 20, 2013

Pericarditis is an inflammation of the pericardium, the protective sac that encloses the heart.

What causes pericarditis?

Pericarditis can be caused by infection, heart attack, autoimmune disorders, chest trauma, cancer, kidney failure, or drugs.

Infections that can cause pericarditis include viral infections, bacterial infections, tuberculosis, and fungal infections. Patients with AIDS frequently develop infections that produce pericarditis.

Autoimmune disorders that can cause pericarditis include rheumatoid arthritis, lupus, and scleroderma.

Pericarditis occurs in up to 15% of patients who have acute myocardial infarctions (heart attacks). There is also a late form of post-heart-attack pericarditis, called Dressler's syndrome, that occurs weeks to months after the heart attack.

Some of the drugs that can produce pericarditis include procainamide, hydralazine, phenytoin, and isoniazid.

Many forms of cancer can metastasize (spread) to the pericardial sac, and produce pericarditis.

In many cases, no definite cause for pericarditis can be identified - this is called "idiopathic" pericarditis.

What symptoms are associated with pericarditis?

The most common symptom caused by pericarditis is chest pain. The pain can be severe, and is often made worse by changing position or with deep breathing. Patients can also develop shortness of breath or fever with pericarditis.

How is pericarditis diagnosed?

Doctors can usually diagnose pericarditis by taking a careful medical history, performing a physical examination, and doing an electrocardiogram (which shows characteristic changes.) Sometimes an echocardiogram can be helpful in making the diagnosis.

What complications can occur with pericarditis?

While pericarditis usually resolves within a few days or a few weeks, three complications can occur. These are cardiac tamponade, chronic pericarditis, or constrictive pericarditis.

Tamponade occurs when fluid accumulating in the pericardial sac (a condition called pericardial effusion) prevents the heart from filling completely. When this happens, the blood pressure drops and the lungs become congested, and the patient experiences weakness, dizziness, lightheadedness and extreme shortness of breath. If treatment is not given, death can ensue. The diagnosis of tamponade is made with an echocardiogram.

Chronic pericarditis occurs when the pericardial inflammation does not resolve within a few weeks. It can be associated with all the symptoms of acute pericarditis, and in addition is often accompanied by particularly large pericardial effusions.

Constrictive pericarditis occurs when a chronically inflamed pericardial sac stiffens and loses its elacticity, which (similar to tamponade) prevents the heart from filling completely. The symptoms are the same as with tamponade, but usually have a much more gradual onset.

How is pericarditis treated?

Acute pericarditis is primarily treated by identifying and treating the underlying cause. The symptoms can usually be improved with anti-inflammatory drugs (usually non-steroidal antiinflammatory drugs, but sometimes steroid therapy is necessary), and analgesics. Most cases of acute pericarditis resolve within a few weeks, and leave no permanent cardiac problems.

Cardiac tamponade is treated by draining the fluid from the pericardial sac, usually through a tiny catheter. Removing the fluid relieves the pressure on the heart, and restores normal cardiac function almost immediately.

Chronic pericarditis is treated by aggressively treating the underlying cause, and draining the large pericardial effusion that is often present. If pericardial effusions continue to recur, surgery can be done to create a permanent opening (a so-called pericardial window) that allows the fluid to drain from the pericardial sac, thus preventing tamponade.

Constrictive pericarditis can be a very difficult therapeutic problem. Symptoms can be treated with bed rest, diuretics, and digitalis, but definitive treatment requires surgery to strip the stiffened pericardial lining away from the heart. This surgery is often quite extensive, and carries significant risk.

Sources:

Imazio M. Contemporary management of pericardial diseases. Curr Opin Cardiol 2012; 27:308.

Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med 2004; 351:2195.

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