Decoding Pericarditis: Causes, Symptoms, and Treatment

Pericarditis is a condition that affects the pericardium, the thin sac that surrounds and protects the heart. It can cause chest pain, fever, and other symptoms. 

Table of Contents

• What is Pericarditis?
• Symptoms of Pericarditis
• Diagnosis of Pericarditis
• Treatment of Pericarditis
• Complications of Pericarditis
• Common Causes of Pericarditis
• Types of Pericarditis
• High-Risk Groups for Pericarditis
• How to Prevent Pericarditis

What is Pericarditis?

Pericarditis refers to inflammation of the pericardium, the fibrous layer surrounding the heart and covering the roots of major blood vessels entering the heart. The pericardium has two layers: the inner visceral layer that adheres to the heart muscle, and the outer parietal layer that forms a sac around the heart. Normally, there is a small amount of fluid between the two layers that lubricates them and allows them to slide smoothly over each other during heartbeats.

When the pericardium becomes inflamed, it can cause friction, swelling, and irritation of the heart. This can result in chest pain, difficulty breathing, and other symptoms. Pericarditis can also affect the function of the heart by restricting its filling or pumping ability, or by causing fluid to accumulate in the pericardial space (pericardial effusion). In some cases, pericarditis can lead to serious complications such as cardiac tamponade (life-threatening compression of the heart by fluid) or constrictive pericarditis (chronic scarring and stiffening of the pericardium).

Symptoms of Pericarditis

The most common symptom of pericarditis is chest pain. About 80% of patients experience chest pain, which is usually sharp or stabbing, and worsens with deep breaths, coughing, or lying down. The pain may radiate to the neck, shoulder, back, or abdomen. Some patients find relief by sitting up or leaning forward.

Other symptoms of pericarditis may include:

• Fever
• Night sweats
• Vomiting
• Diarrhea
• Difficulty breathing
• Heart palpitations
• Fatigue
• Cough
• Swelling of the legs or abdomen

Diagnosis of Pericarditis

The diagnosis of pericarditis is based on the patient's history, physical examination, and various tests. The doctor will ask about the onset, duration, location, and characteristics of the chest pain, as well as any other symptoms or risk factors for pericarditis. The doctor will also listen to the heart sounds with a stethoscope to detect a distinctive friction sound (pericardial rub) that occurs when the inflamed layers of the pericardium rub against each other.

The following tests may be ordered to confirm the diagnosis and assess the severity of pericarditis:

• Blood tests: These can check for signs of inflammation (such as elevated white blood cell count, erythrocyte sedimentation rate, or C-reactive protein), infection (such as bacterial cultures or viral antibodies), or heart damage (such as elevated troponin levels).
• Electrocardiogram (ECG): This is a quick and painless test that records the electrical activity of the heart. It can show changes in the heart rhythm or conduction that may indicate pericarditis or myocardial inflammation. For example, pericarditis patients may show elevated ST segments and inverted T waves in some leads.
• Imaging tests: These can provide visual information about the size, shape, and function of the heart and the pericardium. They can also detect the presence and amount of pericardial effusion. The most commonly used imaging tests for pericarditis are chest X-ray, echocardiogram, cardiac computed tomography (CT) scan, and cardiac magnetic resonance imaging (MRI).

Treatment of Pericarditis

Treatment of pericarditis depends on the underlying cause, the severity of symptoms, and the presence of complications. The main goals of treatment are to reduce inflammation, relieve pain, and prevent recurrence.

In some cases, surgical drainage may be necessary to remove excess fluid from the pericardial sac, which can cause pressure on the heart and impair its function. This procedure is called pericardiocentesis and involves inserting a needle or a catheter into the pericardial space. In severe cases, surgery may be required to remove part or all of the pericardium, which can prevent life-threatening complications such as cardiac tamponade or constrictive pericarditis. This procedure is called pericardiectomy and is usually reserved for patients who do not respond to other treatments.

If the cause of pericarditis is autoimmune-related, such as rheumatoid arthritis or lupus, steroids and anti-inflammatory drugs are used to suppress the immune system and reduce inflammation. These medications can have side effects such as weight gain, increased blood pressure, and increased risk of infections, so they should be used with caution and under close medical supervision.

Tuberculous pericarditis requires antibiotics that target the tuberculosis bacteria, such as isoniazid, rifampin, ethambutol, and pyrazinamide. These medications can also have side effects such as liver damage, nausea, and skin rash, so they should be taken as prescribed and monitored regularly.

Treatment for purulent bacterial infections depends on the specific bacteria that caused the infection. Common antibiotics used for this type of pericarditis include penicillin, ampicillin, ceftriaxone, vancomycin, and clindamycin. These antibiotics can also have side effects such as allergic reactions, diarrhea, and yeast infections, so they should be taken as directed and with plenty of fluids.

For viral pericarditis, initial relief of symptoms may involve anti-inflammatory drugs such as ibuprofen or aspirin. These drugs can help reduce pain and fever, but they can also increase the risk of bleeding and stomach ulcers, so they should be used with caution and for a short period of time. Patients with pericardial effusion and heart compression may require surgery or drainage to prevent further damage to the heart.

Complications of Pericarditis

Pericarditis can lead to serious complications if left untreated or if it recurs frequently. Some of the possible complications include:

• Constrictive pericarditis: This is a chronic condition that causes permanent thickening and scarring of the pericardium, reducing its elasticity and affecting normal heart function. The scarred pericardium restricts the movement of the heart chambers, making it harder for them to fill with blood. This can result in swelling in the legs and abdomen, shortness of breath, fatigue, chest pain, and low blood pressure. Constrictive pericarditis can be treated with surgery or medications that improve blood flow and reduce fluid retention.
• Cardiac tamponade: This is a life-threatening condition that occurs when excessive fluid accumulates in the pericardial sac, compressing the heart and reducing its output. This can cause low blood pressure, rapid heartbeat, fainting, shock, and death. Cardiac tamponade requires immediate medical attention and drainage of the fluid to relieve the pressure on the heart.
• Pericardial effusion: This is a condition that occurs when fluid builds up in the pericardial space due to inflammation or infection. Pericardial effusion can cause chest pain, difficulty breathing, coughing, fever, and palpitations. Pericardial effusion can be diagnosed with an echocardiogram or a chest X-ray and treated with medications or drainage depending on the amount and type of fluid.
• Recurrent pericarditis: This is a condition that occurs when pericarditis comes back after being treated or resolved. Recurrent pericarditis can cause chronic pain and inflammation in the chest area and increase the risk of developing complications such as constrictive pericarditis or cardiac tamponade. Recurrent pericarditis can be prevented by identifying and treating the underlying cause of pericarditis, taking medications as prescribed, avoiding triggers such as stress or physical exertion, and following up with regular check-ups.

Common Causes of Pericarditis

Pericarditis is the inflammation of the pericardium, which is the thin membrane that surrounds the heart. There are many possible causes of pericarditis, but some of the most common are:

• Infections: Viral or bacterial infections are common causes. In Taiwan, viruses like Coxsackie and adenoviruses are prevalent. Bacterial infections may result from Mycobacterium tuberculosis or pyogenic bacteria causing sepsis.
• Autoimmune Diseases: Conditions like lupus or rheumatic fever can trigger an immune response that affects the pericardium.
• Other Causes: Systemic diseases, including radiation therapy, uremia, and malignancies (cancer) can also cause pericarditis.

Some cases of pericarditis have no identifiable cause and are called idiopathic pericarditis.

Types of Pericarditis

Pericarditis can be classified according to the duration and severity of symptoms. The main types are:

• Acute: Symptoms typically last less than three weeks. Acute pericarditis can be caused by infections, heart attacks, or injuries to the heart or chest.
• Subacute: Symptoms persist for three weeks to three months. Subacute pericarditis is often caused by chronic infections such as tuberculosis or fungal infections.
• Chronic: Symptoms last over three months, with a potential for long-term pericardial effusion and sequelae. Chronic pericarditis can be caused by autoimmune diseases, cancer, or constrictive pericarditis.

High-Risk Groups for Pericarditis

Pericarditis can affect anyone, but some people have a higher risk of developing it than others. The high-risk groups include:

• Males aged 20-50. Men are more likely to develop pericarditis than women, especially in their middle age. The reason for this gender difference is not clear, but it may be related to hormonal factors or lifestyle habits.
• Those with autoimmune diseases. People who have inflammatory conditions such as lupus or rheumatoid arthritis have a higher risk of developing pericarditis due to their abnormal immune system.
• Individuals undergoing radiation therapy. Radiation therapy for cancer can damage the heart and the pericardium, leading to inflammation and scarring. This can cause acute or chronic pericarditis, depending on the dose and duration of radiation exposure.
• Patients with uremia. Uremia is a condition where the kidneys fail to filter waste products from the blood. This can cause a buildup of toxins in the body that can irritate the pericardium and cause pericarditis. Uremia is often associated with chronic kidney disease or dialysis.
• Cancer patients. Cancer can spread to the pericardium and cause inflammation or fluid accumulation. Some types of cancer that commonly affect the pericardium are lung cancer, breast cancer, leukemia, and lymphoma.

How to Prevent Pericarditis

Pericarditis is not always preventable, but there are some steps that can reduce the risk of developing it or prevent complications from it. These include:

• Treating infections promptly. Viral or bacterial infections can cause acute pericarditis, so it is important to seek medical attention if you have symptoms such as fever, cough, sore throat, or chest pain. Antibiotics or antiviral medications may be prescribed to treat the infection and prevent it from spreading to the pericardium.
• Taking medications as prescribed. Some medications can cause pericarditis as a side effect, such as blood thinners or anti-seizure drugs. If you are taking these medications, you should follow your doctor's instructions and report any adverse reactions. You should also avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen, as they can worsen pericarditis.
• Managing chronic conditions. If you have a chronic condition that increases your risk of pericarditis, such as autoimmune disease, kidney disease, or cancer, you should follow your treatment plan and monitor your symptoms regularly. You should also consult your doctor before starting or stopping any medications that may affect your heart or pericardium.
• Protecting your heart from injury. Trauma to the chest or heart can cause pericarditis, so you should avoid activities that may injure your heart, such as contact sports or heavy lifting. You should also wear a seat belt when driving and avoid smoking or exposure to secondhand smoke, as they can damage the heart and the pericardium.