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Acute Pericarditis

by Brian D. Hoit, MD

Acute pericarditis is inflammation of the pericardium that begins suddenly, is often painful, and causes fluid and blood components such as fibrin, red blood cells, and white blood cells to enter the pericardial space.

  • Infection and other conditions that inflame the pericardium cause pericarditis.

  • Fever and chest pain, which is sharp and varies with position and movement and occasionally may feel like a heart attack, are common symptoms.

  • Diagnosis is based on symptoms and occasionally by hearing a tell-tale sound when listening to the heartbeat with a stethoscope.

  • People are hospitalized and given drugs to reduce pain and inflammation.

Sometimes the inflammation can cause excess fluid to enter the pericardial space (pericardial effusion). Sometimes, when pericarditis is due to an injury, cancer, or heart surgery, the fluid is blood.

Causes

Acute pericarditis usually results from infection or other conditions that irritate the pericardium. Infection is usually due to a virus such as influenza virus or HIV, but it may be caused by bacteria, parasites (including protozoa), or fungi.

In some inner city hospitals, AIDS is the most common cause of pericarditis with pericardial effusion. In people who have AIDS, a number of infections, including tuberculosis and aspergillosis, may result in pericarditis. Pericarditis due to tuberculosis (tuberculous pericarditis) accounts for less than 5% of cases of acute pericarditis in the United States but accounts for the majority of cases in some areas of India and Africa.

Other conditions can inflame the pericardium, causing acute pericarditis. These conditions include a heart attack, heart surgery, systemic lupus erythematosus (lupus), rheumatoid arthritis, kidney failure, injury, cancer (such as leukemia, breast or lung cancer, and, in people with AIDS, Kaposi sarcoma), rheumatic fever, and radiation therapy. After a heart attack, acute pericarditis develops during the first day or two in 10 to 15% of people and after about 10 days to 2 months in 1 to 3% (subacute pericarditis). Acute pericarditis may occur as a side effect of certain drugs, including anticoagulants (such as warfarin and heparin), penicillin, procainamide (an antiarrhythmic drug), and phenytoin (an anticonvulsant).

Sometimes pericarditis develops after surgery involving the pericardium (pericardiotomy), called postpericardiotomy syndrome.

Sometimes doctors cannot determine the cause of acute pericarditis (called idiopathic or nonspecific pericarditis).

Subacute pericarditis is caused by the same disorders that cause acute pericarditis.

Symptoms

Usually acute pericarditis causes fever and sharp chest pain, which often extends to the left shoulder and sometimes down the left arm. The pain may be similar to that of a heart attack, except that it tends to be made worse by lying down, swallowing food, coughing, or even deep breathing. The accumulating fluid or blood in the pericardial space puts pressure on the heart, interfering with its ability to pump blood. If the pressure is too high, cardiac tamponade—a potentially fatal condition—may occur. Sometimes acute pericarditis does not cause any symptoms.

Pericarditis due to tuberculosis begins insidiously, sometimes without obvious symptoms of lung infection. It may cause fever and symptoms of heart failure, such as weakness, fatigue, and difficulty breathing. Cardiac tamponade may occur.

Acute pericarditis due to a viral infection is usually painful but short-lived and has no lasting effects.

When acute pericarditis develops in the first day or two after a heart attack, symptoms of pericarditis are seldom noticed because symptoms of the heart attack are the main concern (see Acute Coronary Syndromes (Heart Attack). Pericarditis that develops about 10 days to 2 months after a heart attack is usually accompanied by Dressler syndrome (postmyocardial infarction syndrome), which includes fever, pericardial effusion (extra fluid in the pericardial space), pleurisy (inflammation of the pleura, which are the membranes covering the lungs), pleural effusion (fluid between the two layers of the pleura), and joint pain.

In 15 to 25 percent of people with idiopathic pericarditis, symptoms recur on and off for months or years (called recurrent pericarditis).

Diagnosis

Doctors can usually diagnose acute pericarditis based on the person's description of the pain and the sounds heard by listening through a stethoscope placed on the person's chest. Pericarditis can cause a crunching sound similar to the creaking of a leather shoe or a scratchy sound similar to the rustling of dry leaves (pericardial rub). Doctors can often diagnose pericarditis a few hours to a few days after a heart attack based on hearing these sounds.

Usually, doctors also do an electrocardiogram (ECG), which often shows abnormalities caused by the pericarditis. Then doctors look for signs of pericardial effusion by doing a chest x-ray and echocardiography (a procedure that uses ultrasound waves to produce an image of the heart—see Echocardiography and Other Ultrasound Procedures).

Sometimes the cause of pericarditis is obvious, such as a recent heart attack. Other times the cause may not be clear. Echocardiography may suggest the cause—for example, cancer. Blood tests can detect some of the other conditions that cause pericarditis—for example, leukemia, AIDS, other infections, rheumatic fever, and increased levels of urea in the blood resulting from kidney failure. If the cause of pericarditis remains unknown, doctors may withdraw a sample of the pericardial fluid and/or pericardial tissue using a needle inserted through the chest wall (pericardiocentesis). The fluid and tissue are sent to the laboratory for testing.

Prognosis and Treatment

The prognosis for people who have pericarditis depends on the cause. When pericarditis is caused by a virus or when the cause is not apparent, recovery usually takes 1 to 3 weeks. Complications or recurrences can slow recovery. People with cancer that has invaded the pericardium rarely survive beyond 12 to 18 months.

Regardless of the cause, doctors usually hospitalize people with pericarditis, particularly people with high-risk features (fever, subacute onset, recent trauma, oral anticoagulant therapy, failure to improve with use of aspirin or nonsteroidal anti-inflammatory drugs [NSAIDs], and moderate or large pericardial effusions). Acute pericarditis usually responds to colchicine or NSAIDs (such as aspirin and ibuprofen) taken by mouth. Once pain and signs of inflammation have been relieved, the drugs are gradually reduced (tapered—see Nonopioid Analgesics : Nonsteroidal Anti-Inflammatory Drugs). The person is monitored for complications, particularly cardiac tamponade. Intense pain may require an opioid, such as morphine, or a corticosteroid, such as prednisone. Prednisone does not directly reduce pain but relieves it by reducing inflammation. Colchicine also decreases the chance of pericarditis returning later.

Drugs that may cause pericarditis are stopped whenever possible.

Further treatment of acute pericarditis varies, depending on the cause. For people who have kidney failure, increasing the frequency of dialysis usually results in improvement. People who have cancer may respond to chemotherapy or radiation therapy. If a bacterial infection is the cause, treatment consists of antibiotics and surgical drainage of pus from the pericardium.

Fluid may be drained from the pericardium by inserting a thin catheter into the pericardial space (pericardiocentesis). A balloon-tipped catheter may be inserted through the skin. The balloon is then inflated to create a hole (window) in the pericardium. This procedure, called percutaneous balloon pericardiotomy, is usually done as an alternative to surgery when effusions are due to cancer or recur.

Alternatively, a small incision is made below the breast bone, and a piece of the pericardium is removed. Then a tube is inserted into the pericardial space. This procedure, called a subxiphoid pericardiotomy, is often done when effusions are due to bacterial infections. Both procedures require a local anesthetic, can be done at the bedside, allow fluid to drain continuously, and are effective.

If pericarditis caused by a virus, an injury, or an unidentified disorder recurs, aspirin or ibuprofen, sometimes along with colchicine, may provide relief. If these drugs do not help, doctors may give corticosteroids (as long as the cause was not an infection). The corticosteroids are sometimes injected into the pericardial space. If drug treatment is ineffective, the pericardium may be removed surgically.

When acute pericarditis occurs within the first few hours or days after a heart attack, treatment for the heart attack, including aspirin and stronger analgesics such as morphine, can usually reduce any discomfort due to pericarditis.

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • PANHEPRIN
  • COUMADIN
  • DILANTIN
  • No US brand name
  • ADVIL, MOTRIN IB
  • RAYOS
  • DURAMORPH PF, MS CONTIN
  • COLCRYS