Pericarditis (Inflammation of the Heart Membrane)

Pericarditis is a term for inflammation of the pericardium, the membrane around the heart. The pericardium, which keeps the heart in place and prevents friction from surrounding organs, is a sac comprised of two layers of tissue with lubricating fluid in between. When pericarditis occurs, this tissue becomes inflamed and may rub against the heart, causing chest pain that is sometimes mistaken for a heart attack. 1 2 3

Pericarditis is a relatively common heart condition. It is estimated to be the cause of 5 percent of visits to hospital emergency rooms for chest pain. The condition can affect people of all ages, but is most common in men between 20 and 50 years old. 1 4

In most cases, the cause of pericarditis is unknown. Viral infections are a common trigger, but the cause may also be: 3

• Another type of infection
• A chest injury
• Heart attack
• Heart surgery
• Another medical condition, or
• Certain medicines, such as penicillin and some chemotherapy drugs

Pericarditis may develop suddenly and be short-lived (acute), or develop over time and be a chronic condition.

Most cases of acute pericarditis are mild and clear up on their own within a few days to a number of weeks with rest and medication to reduce the inflammation. However, roughly 20 to 50 percent of people treated for acute pericarditis may go on to develop recurrent pericarditis, which requires long-term treatment.

Though uncommon in pericarditis, life-threatening complications such as cardiac tamponade and constrictive pericarditis may occur and necessitate immediate intervention. In all cases, the prognosis depends largely on the cause of the pericarditis. 1 2 4

The most common symptom of pericarditis is chest pain. 5 This may develop suddenly and be experienced as a sharp, stabbing sensation behind the breastbone on the left side of the body. However, for some people there may be a constant, steady pain, or more of a dull ache or feeling of pressure.

The chest pain may radiate into the left shoulder and neck, and tends to be worse when breathing deeply, coughing, swallowing or lying down. Sitting up or leaning forward may ease the pain.

Individuals experiencing pericarditis may also present with: 2 4 5

• Fever
• Fatigue or weakness
• Shortness of breath (particularly if cardiac tamponade develops)
• Difficulty breathing or rapid breathing
• Rapid heartbeat
• Palpitations (the feeling that the heart is skipping a beat or pounding)
• Nausea
• Chills
• Cough
• Swelling of the legs or abdomen
• Low blood pressure (in severe cases)

If any symptoms are present and pericarditis is suspected, medical advice should be sought immediately.

Viruses are the most common cause of acute pericarditis. A number of different viruses are associated with the heart condition, including, among others: 4 5

• Coxsackieviruses
• Echoviruses
• Adenoviruses (e.g. the common cold, pneumonia)
• HIV
• Influenza
• Hepatitis viruses

Other causes of pericarditis include: 3 4 5

• Bacterial infection (usually spread from nearby tissues or wounds after heart surgery)
• Tuberculosis
• Fungi and parasites
• Kidney failure
• Heart attack or heart surgery
• Chest injury (e.g., a stab wound or car accident)
• Radiotherapy to treat cancers in the chest
• Cancer that has spread from another part of the body (rare)
• Autoimmune conditions (e.g., rheumatoid arthritis and systemic lupus erythematosus)
• Inflammatory bowel disease (e.g., ulcerative colitis and Crohn’s disease
• Certain medications (e.g., penicillin, phenytoin, warfarin and rifampin)

In many cases, no cause can be identified and the condition is termed idiopathic pericarditis.

The cause of recurrent pericarditis is unknown, though it is thought that irregularities in the immune system may play a role. Pericarditis may result from autoimmune conditions such as systemic lupus erythematosus, rheumatoid arthritis and scleroderma, where the immune system mistakenly attacks healthy tissue or cells. 1

The first step in diagnosing pericarditis will be for a doctor to take the affected person’s medical history and perform a physical examination. The doctor will typically listen to the heart using a stethoscope to check for a common sign of pericarditis known as a pericardial friction rub (or pericardial rub). This is a distinct rasping or grating noise caused by the inflamed pericardial layers rubbing against each other. 3 5

The doctor will also listen for signs of excess fluid in the pericardium (pericardial effusion) or lungs (pleural effusion). A small amount of excess fluid in the pericardium is not a cause for great concern and usually clears up on its own. However, if the fluid builds up, it may lead to the potentially life-threatening condition known as cardiac tamponade. This can cause serious complications, including compromised pumping function of the heart, and requires urgent medical treatment. 5

If pericarditis is suspected, the doctor may order imaging and laboratory tests to confirm the diagnosis and differentiate it from other conditions such as heart attack and peptic ulcer disease. These tests could include any of the following: 2 3 4 5

• Electrocardiogram (ECG or EKG): A test that traces the heart’s electrical activity. Pericarditis may produce abnormal patterns.
• Chest X-ray: While most people with acute pericarditis have a normal X-ray, this test can show an enlarged heart where there is significant pericardial effusion, and help rule out other causes.
• Echocardiogram: A heart ultrasound scan that shows the size, shape and movement of the heart, and whether fluid has accumulated in the pericardium. An echocardiogram can indicate whether the fluid is causing cardiac tamponade.
• Blood tests: These can detect underlying infections, as well as the presence of inflammatory markers.

In addition, the doctor may request a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan to obtain a more detailed image of the heart and surrounding organs. If tuberculosis is suspected, the doctor may also decide to take a sample of fluid from the pericardium, using a needle and syringe.

Treatment depends on the severity and type of the pericarditis. The goals are to relieve pain and reduce inflammation, address the underlying cause where possible, and detect and manage possible complications. 7

A doctor will assess whether the affected person can safely be treated at home, or whether they need to be admitted to hospital. A person is more likely to be admitted to hospital as they have an increased risk of complications if any of the following applies: 3

• A high fever
• Signs of cardiac tamponade
• Signs of serious pericardial effusion
• Recent treatment with blood thinners

In addition, if outpatient treatment is not successful, hospital admission will typically be required.

Where hospitalization is unnecessary, a doctor may advise the affected person to rest at home and prescribe anti-inflammatory medication, such as aspirin or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen to reduce pain and inflammation. 8 5 7

If the pain is severe or the symptoms do not improve within two weeks, colchicine, a medication that reduces inflammation, may be prescribed. Colchicine improves the outlook of pericarditis and reduces the likelihood of it recurring. 3 4 5 7

If the pericarditis does not respond to this treatment, a course of corticosteroids (such as prednisone) may be recommended. Because the risk of recurrent pericarditis may increase when steroids are used, they tend to be prescribed with caution. In cases of acute pericarditis caused by myocardial infarction (heart attack), corticosteroids cannot be used, as they may negatively affect the healing process. 3 4 5 7

If the cause of pericarditis is bacterial, antibiotics may be prescribed. 3

Repeat episodes of pericarditis are typically managed in the same way as acute pericarditis, with anti-inflammatory medication prescribed to relieve pain and reduce inflammation. A long-term course of colchicine may help prevent a relapse of symptoms. Corticosteroids are usually used as a last resort.

Recurrent pericarditis, also known as relapsing pericarditis, may be incessant – where there is a relapse within six weeks of stopping treatment (this may be a continuation of the first episode of pericarditis), or intermittent – where more than six weeks pass between relapses (a true recurrence). The condition may be debilitating. 3 9 10

Where recurrent pericarditis is severe and unresponsive to treatment, surgery may be recommended. The procedure is called a pericardiectomy and involves the removal of a part or most of the pericardium. 3 9

This is a rare but serious potential complication of pericarditis. It develops when the pericardium is inflamed for a long period of time, and subsequently thickens and contracts around the heart, compromising its functioning. Symptoms of constrictive pericarditis may include: 3 5

• Swelling of the legs, ankles and other parts of the body
• Tiredness
• Shortness of breath

Constrictive pericarditis may be transient or chronic. Where the condition is chronic, a pericardiectomy is typically the only effective treatment. If constrictive pericarditis is suspected, medical advice should be sought immediately. 2 9

This condition involves fluid accumulating slowly between the two layers of the pericardium without necessarily leading to cardiac tamponade. Symptoms may include chest pain, lightheadedness and shortness of breath. 9 11

Large, persistent pericardial effusions may be drained, or the condition may be treated with one of the following interventions: 4

• Balloon pericardiotomy: Where a balloon-tipped catheter (thin tube) is used to create a hole in the pericardium to drain the fluid. 12
• Surgical pericardial window: Where a small part of the pericardium is opened to drain the fluid. Also known as a subxiphoid pericardiostomy. 13
• Sclerosis of the pericardial sac with tetracycline or other substances: This is the administration of a substance to stiffen the tissue, so that the two layers can stick together. Doing this can help prevent a build-up of fluid. 14

This is a rare but life-threatening possible complication of pericarditis, where fluid builds up in the pericardium and exerts pressure on the heart, compromising its ability to function. Cardiac tamponade seems to be more common in cases of pericarditis caused by tuberculosis or cancer. Symptoms may develop suddenly (within minutes or hours) and can include:

• Weakness
• Faintness
• Fatigue
• Nausea
• Severe shortness of breath
• Palpitations (the feeling that the heart is skipping a beat or pounding)
• Confusion
• Low blood pressure with blurred vision and fainting
• Loss of consciousness

Emergency treatment is essential and typically involves a procedure called pericardiocentesis, where excess fluid in the pericardium is removed via the chest wall using a needle or tube. 2 3 8 9

• Idiopathic pericarditis
• Acute pericarditis
• Recurrent pericarditis
• Chronic pericarditis

Q: What is effusive-constrictive pericarditis?
A: Effusive-constrictive pericarditis is a serious condition in which constrictive pericarditis is present together with pericardial effusion (often with cardiac tamponade). It seems to be more prevalent in cases of pericarditis caused by tuberculosis. Treatment may include pericardiocentesis to relieve pressure on the heart muscle, anti-inflammatory medications, corticosteroids, and, in some cases, pericardiectomy. 9 15 16

Q: Can pericarditis be prevented?
A: It is not usually possible to prevent pericarditis. However, steps can be taken to reduce the likelihood of experiencing a repeat episode of pericarditis, chronic pericarditis, or complications from pericarditis. These steps include: 7

• Seeking treatment without delay
• Following the treatment plan (for example, taking colchicine as prescribed)
• Listening to a doctor’s advice for ongoing medical care