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Chronic Pericarditis

By

Brian D. Hoit

, MD, Case Western Reserve University School of Medicine

Last full review/revision Nov 2020| Content last modified Nov 2020
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Chronic pericarditis is inflammation of the pericardium (the flexible two-layered sac that envelops the heart) that begins gradually, is long-lasting, and results in fluid accumulation in the pericardial space or thickening of the pericardium.

  • Symptoms may include shortness of breath, coughing, and fatigue.

  • Echocardiography and sometimes other tests are used to make the diagnosis.

  • The cause, if known, is treated, or salt restriction and diuretics may be used to relieve symptoms.

  • Sometimes surgery to remove the pericardium is needed.

Pericarditis is considered chronic if it lasts longer than 6 months. There are two main types of chronic pericarditis.

  • Chronic effusive pericarditis

  • Chronic constrictive pericarditis

In chronic effusive pericarditis, fluid slowly accumulates in the pericardial space, between the two layers of the pericardium.

Chronic constrictive pericarditis, which is rare, usually results when scarlike (fibrous) tissue forms throughout the pericardium. The fibrous tissue tends to contract over the years, compressing the heart. The compression prevents the heart from filling normally and causes a form of heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more Heart Failure (HF) . However, because of the compression, the heart does not enlarge as it does in most types of heart failure. Because higher pressure is needed to fill the compressed heart, pressure in the veins that return blood to the heart increases. As a result of the increased venous pressure, fluid leaks out and accumulates in other areas of the body, such as under the skin. Occasionally, constrictive pericarditis occurs more quickly (for example, within a few weeks after heart surgery) and is considered subacute.

Causes of Chronic Pericarditis

Usually, the cause of chronic constrictive pericarditis is also unknown. The most common known causes are viral infections, radiation therapy for breast cancer or lymphoma Overview of Lymphoma Lymphomas are cancers of lymphocytes, which reside in the lymphatic system and in blood-forming organs. Lymphomas are cancers of a specific type of white blood cells known as lymphocytes. These... read more Overview of Lymphoma in the chest, and heart surgery. Chronic constrictive pericarditis may also result from any condition that causes acute pericarditis Causes Acute pericarditis is inflammation of the pericardium (the flexible two-layered sac that envelops the heart) that begins suddenly, is often painful, and causes fluid and blood components such... read more Causes , such as rheumatoid arthritis, systemic lupus erythematosus (lupus), a previous injury, or a bacterial infection.

Previously, tuberculosis Tuberculosis (TB) Tuberculosis is a chronic contagious infection caused by the airborne bacteria Mycobacterium tuberculosis. It usually affects the lungs. Tuberculosis is spread mainly when people breathe air... read more Tuberculosis (TB) was the most common cause of chronic pericarditis in the United States, but today tuberculosis accounts for only 2% of cases. In Africa and India, tuberculosis is still the most common cause of all forms of pericarditis.

Symptoms of Chronic Pericarditis

Symptoms include

  • Shortness of breath

  • Coughing

  • Fatigue

Shortness of breath and coughing occur because the high pressure in the veins of the lungs forces fluid into the air sacs.

Fatigue occurs because the abnormal pericardium interferes with the heart's pumping action, so that the heart cannot pump enough blood to meet the body's needs.

Other common symptoms are accumulation of fluid in the abdomen (ascites) and in the legs (edema). Sometimes fluid accumulates in the space between the two layers of the pleura, the membranes covering the lungs (a condition called pleural effusion Pleural Effusion Pleural effusion is the abnormal accumulation of fluid in the pleural space (the area between the two layers of the thin membrane that covers the lungs). Fluid can accumulate in the pleural... read more Pleural Effusion ). However, chronic pericarditis does not usually cause pain.

Sometimes the inflammation occurs without symptoms.

Chronic effusive pericarditis may cause few symptoms if fluid accumulates slowly. When fluid accumulates slowly, the pericardium can stretch gradually, so that symptoms caused by severe pressure on the heart (cardiac tamponade Cardiac Tamponade Cardiac tamponade is pressure on the heart by blood or fluid that accumulates in the two-layered sac around the heart (pericardium). This disorder interferes with the heart's ability to pump... read more ) may not develop. However, if fluid accumulates rapidly, or the pericardium is not able to stretch sufficiently, the heart can become compressed and cardiac tamponade may occur.

Diagnosis of Chronic Pericarditis

  • Echocardiography

  • Sometimes cardiac catheterization or imaging using MRI or CT

Echocardiography Echocardiography and Other Ultrasound Procedures Ultrasonography uses high-frequency (ultrasound) waves bounced off internal structures to produce a moving image. It uses no x-rays. Ultrasonography of the heart (echocardiography) is one of... read more Echocardiography and Other Ultrasound Procedures is often done. It can detect the amount of fluid in the pericardial space and the formation of fibrous tissue around the heart. It can also confirm the presence of cardiac tamponade and suggest the presence of constrictive pericarditis.

Chest x-ray may detect calcium deposits in the pericardium. These deposits develop in nearly half of the people who have chronic constrictive pericarditis.

The diagnosis can be confirmed in one of two ways.

  • Cardiac catheterization

  • Imaging

A biopsy may be done to help determine the cause of chronic pericarditis—for example, tuberculosis. A small sample of the pericardium is removed during exploratory surgery and examined under a microscope. Alternatively, a sample can be removed using a pericardioscope (a fiberoptic tube used to view the pericardium and to obtain tissue samples) inserted through an incision in the chest.

Laboratory tests on samples of blood and fluid from the pericardium may also be needed to help determine the cause of pericarditis.

Did You Know...

  • People can actually live without a pericardium, but surgery to remove it can be risky.

Treatment of Chronic Pericarditis

  • Treatment of the underlying disorder

  • Sometimes removal of the pericardial fluid or the pericardium

  • For chronic constrictive pericarditis, salt restriction and diuretics to relieve symptoms

Known causes of chronic effusive pericarditis are treated when possible. If heart function is normal, doctors take a wait-and-see approach.

Chronic constrictive pericarditis

For people with chronic constrictive pericarditis, restriction of salt in the diet and diuretics (drugs that increase the excretion of fluid) may relieve symptoms.

The only possible cure for chronic constrictive pericarditis is surgical removal of the pericardium. Surgery cures about 85% of people. However, because the risk of death from surgery is 5 to 15% (and is higher in people who have severe heart failure), most people do not have surgery unless the disease substantially interferes with daily activities.

Doctors usually wait until symptoms are severe—but before symptoms are so severe that they occur while the person is resting—to do the surgery. Restricting salt in the diet and taking diuretics can control the condition for months or even years and may be the only treatment required if constrictive pericarditis is subacute (for example, occurs after heart surgery).

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