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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.

  • Doctors base the diagnosis on symptoms and occasionally by hearing a tell-tale sound when listening to the heartbeat with a stethoscope.

  • People are often 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

Causes of acute pericarditis include

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.

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). 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 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.

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), pleuritic pain (pain due to 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

  • Electrocardiography

  • Chest x-ray

  • Echocardiography

  • Tests to identify the cause

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 electrocardiography (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).

Tests for the cause of pericarditis

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, the image shown on the echocardiogram may suggest 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

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.

Treatment

  • Anti-inflammatory drugs, such as nonsteroidal anti-inflammatory drugs or colchicine

  • Treatment of the underlying disorder, such as cancer

  • Infrequently, surgical treatment such as pericardiotomy

Regardless of the cause, doctors sometimes 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). The person is monitored for complications, particularly cardiac tamponade.

Anti-inflammatory drugs

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. Colchicine also decreases the chance of pericarditis returning later. Intense pain may require an opioid, such as morphine. Prednisone, a corticosteroid, does not directly reduce pain but relieves it by reducing inflammation.

Treating the underlying disorder

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.

Drugs that may cause pericarditis are stopped whenever possible.

People who have cancer may respond to chemotherapy or radiation therapy.

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, doctors may remove the pericardium surgically.

If a bacterial infection is the cause, treatment consists of antibiotics and surgical drainage of pus from the pericardium.

Surgical treatment

Fluid may be drained from the pericardium by inserting a thin catheter into the pericardial space (pericardiocentesis).

Sometimes a balloon-tipped catheter is 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 person's bedside, allow fluid to drain continuously, and are effective.

Drugs Mentioned In This Article

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

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