(See also Overview of Pericardial Disease Overview of Pericardial Disease Pericardial disease affects the pericardium, which is the flexible two-layered sac that envelops the heart. The pericardium helps keep the heart in position, helps prevent the heart from overfilling... read more and Acute Pericarditis Acute Pericarditis 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 .)
Pericarditis is considered chronic if it lasts longer than 6 months. There are two main types of chronic 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 . 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.
Usually, the cause of chronic effusive pericarditis is unknown. However, it may be caused by cancer, 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 , or an underactive thyroid gland (hypothyroidism Hypothyroidism Hypothyroidism is underactivity of the thyroid gland that leads to inadequate production of thyroid hormones and a slowing of vital body functions. Facial expressions become dull, the voice... read more ), and it occasionally occurs in people with chronic kidney disease Chronic Kidney Disease Chronic kidney disease is a slowly progressive (months to years) decline in the kidneys’ ability to filter metabolic waste products from the blood. Major causes are diabetes and high blood pressure... read more .
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 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 , 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 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.
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 ). 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.
Symptoms provide important clues that a person has chronic pericarditis, particularly if there is no other reason for reduced heart performance—such as high blood pressure High Blood Pressure High blood pressure (hypertension) is persistently high pressure in the arteries. Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying... read more , coronary artery disease Overview of Coronary Artery Disease (CAD) Coronary artery disease is a condition in which the blood supply to the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The coronary... read more , cardiomyopathy Overview of Cardiomyopathy Cardiomyopathy refers to progressive impairment of the structure and function of the muscular walls of the heart chambers. There are three main types of cardiomyopathy: Dilated cardiomyopathy... read more , or a heart valve disorder Overview of Heart Valve Disorders Heart valves regulate the flow of blood through the heart's four chambers—two small, round upper chambers (atria) and two larger, cone-shaped lower chambers (ventricles). Each ventricle has... read more .
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 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 Cardiac Catheterization and Coronary Angiography Cardiac catheterization and coronary angiography are minimally invasive methods of studying the heart and the blood vessels that supply the heart (coronary arteries) without doing surgery. These... read more can be used to measure blood pressure in the heart chambers and major blood vessels. These measurements help doctors distinguish chronic pericarditis from similar disorders.
Magnetic resonance imaging Magnetic Resonance Imaging (MRI) In magnetic resonance imaging (MRI), a strong magnetic field and very high frequency radio waves are used to produce highly detailed images. MRI does not use x-rays and is usually very safe... read more (MRI) or computed tomography Computed Tomography (CT) In computed tomography (CT), which used to be called computed axial tomography (CAT), an x-ray source and x-ray detector rotate around a person. In modern scanners, the x-ray detector usually... read more (CT) can be used to determine the thickness of the pericardium. Normally, the pericardium is less than 1/8 inch (3 millimeters) thick, but in chronic constrictive pericarditis, it is usually about one fifth of an inch (5 millimeters) thick or more.
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.
Known causes of chronic effusive pericarditis are treated when possible. If heart function is normal, doctors take a wait-and-see approach.
If the disorder causes symptoms or if an infection is suspected, balloon pericardiotomy Surgical treatment 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 , needle drainage (pericardiocentesis), or surgical drainage Treating the underlying disorder 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 may be done.
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).