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Pericarditis

Pericarditis

Pericarditis describes the condition where the thin membrane lining the heart becomes inflamed. Most often, acute pericarditis is self-limiting and will resolve within a few weeks. However, it may recur and is considered chronic if the symptoms persist for more than 6-12 months.

 

Some people that develop pericarditis can have complications such as fluid accumulation around the heart (pericardial effusion) or heart compression (pericardial constriction) that may require emergency or surgical interventions.

 

The pericardium is a thin membrane that encloses the heart and the base of the great vessels of the heart (aorta, vena cava, pulmonary artery and pulmonary vein). It is composed of to layers. The visceral layer is attached to the heart surface and then folds back on itself to form the parietal layer. This forms a small place that normally holds less than 50cc of fluid.

 

The pericardium holds the heart in its appropriate position in the chest and protects it from infection or tumors that might spread directly from other organs near the heart, such as the lung or esophagus. The pericardium also prevents the heart from dilating too much, which allows the heart muscle fibers to maintain their ideal length to contract or squeeze forcefully.

 

Most often, pericarditis is self-limiting with medical care directed toward controlling the major symptom of pain. However, chronic inflammation of the pericardium can cause scarring that prevents the heart from beating appropriately and surgery may be required.

 

Inflammation can occur in many places in the heart. Pericarditis describes an inflammation of the membrane lining of the heart. It is different than myocarditis (inflammation of the heart muscle) and endocarditis (inflammation of the heart valves).

Symptoms

Chest pain is the most common pericarditis symptom that causes a patient to seek medical care. The pain is usually sharp and pleuritic, meaning that it hurts worse to take a deep breath. It is often worse when lying flat and is eased somewhat by leaning forward. The pain can radiate to the back or left shoulder.

 

Fever, weakness and malaise may be present, as with any other inflammatory process in the body.

 

If the pericarditis persists, fluid can accumulate around the heart, termed a pericardial effusion. The effusion can raise the pressure inside the pericardium causing cardiac tamponade that prevents the heart muscle from contracting and beating adequately. This can cause symptoms of shortness of breath, weakness, syncope (fainting) and in some people, death.

 

Constrictive pericarditis occurs when the pericardium scars down and adheres to the heart surface; it can prevent the heart from expanding to receive blood returning from the body. This type of pericarditis can present with swelling (edema) of the feet, ankles and legs.

 

Exams and Tests

 

The diagnosis of pericarditis begins with a careful history taken by the health care practitioner. While most cases of pericarditis have an unknown cause, it is important to explore situations where an underlying disease can be treated. History of recent illness, heart attack, surgery, or underlying inflammatory illness may give a clue as to the potential cause of pericarditis.

 

When a patient has symptoms with chest pain, the health care practitioner will always be concerned about other potential diagnoses including atherosclerotic heart disease withangina or heart attack, aortic dissection, pulmonary embolism, as well as less life-threatening illnesses such as esophagitis and gastritis.

 

While physical examination will concentrate on the heart examination, general assessment of the patient may find the presence of fever, a rapid heartbeat (tachycardia) or rapid breathing rate (tachypnea).

 

Abnormal heart sounds may be heard when using a stethoscope to listen to the heart. Hearing a friction rub often confirms the presence of pericarditis, though not the cause. A friction rub occurs when the two inflamed pericardial surfaces, rub against each other with every heart beat. The friction rub which can be difficult to hear, may sometimes be better heard when the patient leans forward.

 

Beck's triad describes the signs of cardiac tamponade on physical examination. Low blood pressure, jugular vein distention in the neck and muffled heart tones make up the triad. The tamponade prevents the heart from distending to accept blood returning from the body, causing veins to distend. The heart cannot pump blood appropriately causing the blood pressure to fall and the fluid decreases the heart sound volume making it difficult to he heard by the health care practitioner.

 

An electrocardiogram (EKG) may reveal common electrical conduction abnormalities that are seen in pericarditis.

 

Chest X-rays may be normal, but if there is a significant pericardial effusion, the heart shape may be abnormal. It is sometimes described as globular or flask shaped.

 

An echocardiogram or ultrasound exam of the heart may demonstrate fluid or effusion. It is an emergent test if cardiac tamponade is suspected.

 

While the diagnosis of pericarditis is often made clinically and confirmed with an electrocardiogram or other tests such as CT scan, ultrasound, or echocardiogram, blood tests may be helpful in the diagnosing the underlying cause.

 

  • A complete blood count (CBC) may reveal an elevated white blood cell countassociated with a potential bacterial infection, though the white cell count may be elevated due to stress
  • Blood chemistry tests can evaluate kidney function to explore for uremia (excessive amounts of urea in the blood) or kidney failure
  • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are non-specific markers for inflammation within the body. 
  • Cardiac enzymes such as troponin or myoglobin may be measured since pericarditis may be associated with heart attack or myocarditis (an inflammation of the heart muscle).
  • Other laboratory tests may be considered depending upon the situation and may include blood cultures for bacterial or viral infections, tuberculin testing, and thyroid function tests among others.

 

Other tests may be used to further define the extent and in some cases, the source of pericardial fluid. Most frequently, CT or MRI scans of the heart and surrounding structures are examined.

 

In certain situations such as pericardial tamponade, pericardiocentesis may be performed. A long needle is inserted through the chest wall into the pericardial space and fluid is removed to reduce pressure on the heart muscle tissue and allow the heart to beat properly. This fluid can be sent for analysis to explore possible infections, abnormal cells, and other causes of inflammation.

Causes

Constrictive pericarditis occurs when the pericardium scars down and adheres to the heart surface; it can prevent the heart from expanding to receive blood returning from the body. This type of pericarditis can present with swelling (edema) of the feet, ankles and legs.

Treatment

Medicines that reduce inflammation are the primary treatment for pericarditis. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, are used to decrease the inflammation and fluid accumulation in the pericardial sac. Occasionally, a short course of narcotic pain medication [codeine, hydrocodone (Vicodin) or oxycodone (OxyContin, Roxicodone)] will be needed. In recurrent cases, especially in immunologically-mediated causes, corticosteroids are often very effective. Treatment of the underlying cause of pericarditis is essential and will be based on the disease process.

 

Pericardiocentesis, a procedure where a thin needle is inserted through the chest wall into the pericardial sac, may be considered if too much fluid is present (see cardiac tamponade below), or to aid in establishing the cause of the pericarditis (for example, infection, cancer, etc.) by analyzing the fluid that is removed. Pericardotomy (cutting a hole in the pericardial sac) or pericardectomy (removing the sac completely) may be needed for recurrent pericarditis of scarring within the pericardial sac.

 

What are the complications of pericarditis?

 

Cardiac tamponade

 

If there is enough fluid in the pericardia sac, there may be enough pressure on the outside of the heart to prevent it from beating adequately to push blood to the body and lungs. The pressure within the sac itself needs to be higher than the pressure within the heart chambers, but symptoms gradually progress as the heart function is compromised. This can be a true medical emergency.

 

The symptoms tend to be nonspecific but can include shortness of breath and difficulty with exercise or doing daily activities. Additional complaints may be due to the illness or disease that caused the effusion to accumulate in the first place.

 

Upon physical examination the following signs may be present:

 

  • blood pressure may be low;
  • veins in the neck can dilate (jugular venous distention); 
  • fluid can accumulate in parts of the body that are below the heart due to gravity (edema); 
  • heart sounds can be muffled because the fluid in the pericardial sac blocks normal heart sounds from being heard with a stethoscope; 
  • lung examination may reveal fluid back up as well.

 

Testing likely will include an urgent EKG, chest x-ray and echocardiogram.

 

Cardiac tamponade may be a true emergency that is treated by pericardiocentesis, a procedure where a long needle is inserted through the chest wall into the pericardial sac and fluid is removed. This relieves the pressure within the sac and temporarily resolves the acute emergency. A plastic tube or catheter may be left in the chest until the underlying illness that cause the tamponade is addressed and further accumulation of fluid in the pericardium is prevented. Admission to the hospital is usually required.

 

Constrictive pericarditis

 

If the heart or the pericardial sac is damaged because of trauma, or disease invades the space, then there can be scarring of the space. This scarring can prevent the heart from expanding to collect blood from the body. This limits the ability of the heart to function because it cannot collect blood and pump it to the lungs and then back to the body. The heart is constricted and cannot dilate normally. There may or may not be fluid detectable around the heart.

 

Bleeding into the pericardium from trauma or from a heart operation is the most common cause of constrictive pericarditis, but tumors, or infections liketuberculosis or fungus can also be the cause.

 

The constriction occurs slowly over time and will cause shortness of breath on exertion and decreased ability to exercise. Swelling in the legs and the abdomen may exist because it is difficult for blood to return to the heart and fluid leaks out into the tissues.

 

Diagnosis is made again by history, physical examination, EKG, echocardiography and sometimes computerized tomography (CT) of the chest.

 

If there is significant scarring of the pericardial sac, pericardotomy, an operation to split open the pericardium to free up the constriction around the heart may be required to improve function.

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