Section 3. Heart and Blood Vessel Disorders

Chapter 30. Pericardial Disease

Topics: Introduction | Acute Pericarditis | Chronic Pericarditis

Acute Pericarditis

Acute pericarditis is inflammation of the pericardium that begins suddenly, is often painful, and causes fluid and blood components such as fibrin, red blood cells, and white blood cells to pour into the pericardial space.

Acute pericarditis usually results from infection or other conditions that irritate the pericardium. Infection is usually due to a virus but may be caused by bacteria, parasites (including protozoa), or fungi.

In some inner city hospitals, AIDS is the most common cause of pericarditis with extra fluid in the pericardial space (pericardial effusion). In people who have AIDS, a number of infections, including tuberculosis, may result in pericarditis. Pericarditis due to tuberculosis (tuberculous pericarditis) accounts for less than 5% of cases of acute pericarditis in the United States but accounts for the majority of cases in some areas of India and Africa.

Other conditions can irritate the pericardium and thus can cause acute pericarditis. These conditions include a heart attack, heart surgery, systemic lupus erythematosus, rheumatoid arthritis, kidney failure, injury, cancer (such as leukemia and, in people with AIDS, Kaposi's sarcoma), rheumatic fever, an underactive thyroid gland (hypothyroidism), radiation therapy, and leakage of blood from an aortic aneurysm (a bulge in the wall of the aorta). After a heart attack, acute pericarditis develops during the first day or two in 10 to 15% of people and after about 10 days to 2 months in 1 to 3%. Acute pericarditis may occur as a side effect of certain drugs, including anticoagulants (such as warfarin and heparin), penicillin, procainamide (an antiarrhythmic drug), phenytoin (an anticonvulsant), and phenylbutazone (a nonsteroidal anti-inflammatory drug).

Symptoms

Usually, acute pericarditis causes fever and chest pain, which typically extends to the left shoulder and sometimes down the left arm. The pain may be similar to that of a heart attack, except that it tends to be made worse by lying down, swallowing food, coughing, or even deep breathing. The accumulating fluid or blood in the pericardial space puts pressure on the heart, interfering with its ability to pump blood. If the pressure is too high, cardiac tamponade--a potentially fatal condition--may occur.

Acute pericarditis due to tuberculosis begins insidiously, sometimes without obvious symptoms of lung infection. It may produce fever and symptoms of heart failure. Cardiac tamponade may occur.

See the figure Cardiac Tamponade: The Most Serious Complication of Pericarditis.

Acute pericarditis due to a viral infection is usually painful but short-lived and has no lasting effects.

When acute pericarditis develops in the first day or two after a heart attack, symptoms of pericarditis are seldom noticed, because symptoms of the heart attack are the main concern (see Section 3, Chapter 33). Pericarditis that develops about 10 days to 2 months after a heart attack is usually accompanied by Dressler's syndrome (post-myocardial infarction syndrome), which includes fever, pericardial effusion (extra fluid in the pericardial space), pleurisy (inflammation of the pleura, which are the membranes covering the lungs), pleural effusion (fluid between the two layers of the pleura), and joint pain.

Diagnosis

Doctors can diagnose acute pericarditis based on the person's description of the pain and the sounds heard by listening through a stethoscope placed on the person's chest. Pericarditis can produce a crunching sound similar to the creaking of a leather shoe or a scratchy sound similar to the rustling of dry leaves (pericardial rub). Doctors can often diagnose pericarditis a few hours to a few days after a heart attack based on hearing these sounds.

A chest x-ray and echocardiography (a procedure that uses ultrasound waves to produce an image of the heart) (see Section 3, Chapter 21) may be useful because they can usually detect too much fluid in the pericardial space. Echocardiography may suggest the cause--for example, cancer. Electrocardiography (ECG) may be performed (see Section 3, Chapter 21). ECG results may suggest pericarditis, but distinguishing pericarditis from a heart attack based on ECG results may be difficult. Blood tests can detect some of the conditions that cause pericarditis--for example, leukemia, AIDS, other infections, rheumatic fever, and increased levels of urea in the blood resulting from kidney failure.

Treatment and Prognosis

Regardless of the cause, doctors usually hospitalize people with pericarditis, give them drugs that reduce inflammation and pain (such as aspirin, ibuprofen, or another nonsteroidal anti-inflammatory drug (see Section 6, Chapter 78)), and watch for complications, particularly cardiac tamponade. Intense pain may require an opioid, such as morphine, or a corticosteroid, such as prednisone. Prednisone does not directly reduce pain but relieves it by reducing inflammation. Drugs that may cause pericarditis are discontinued whenever possible.

Further treatment of acute pericarditis varies, depending on the cause. For people who have kidney failure, increasing the frequency of dialysis usually results in improvement. People who have cancer may respond to chemotherapy or radiation therapy, but often, the pericardium is surgically removed. If a bacterial infection is the cause, treatment consists of antibiotics and surgical drainage of pus from the pericardium.

Fluid may be drained from the pericardium by inserting a balloon-tipped catheter through the skin and inflating the balloon to create a hole (window) in the pericardium. This procedure, called percutaneous balloon pericardiotomy, is usually performed for effusions that are due to cancer or that recur. Alternatively, a small incision is made below the breast bone, and a piece of the pericardium is removed. Then a tube is inserted into the pericardial space. This procedure, called a subxiphoid pericardiotomy, is often performed for effusions due to bacterial infections. Both procedures require a local anesthetic, can be performed at the bedside, allow fluid to drain continuously, and are effective.

If pericarditis resulting from a virus, an injury, or an unidentified disorder recurs, aspirin, ibuprofen, or corticosteroids may provide relief. For some people, colchicine is effective. If drug treatment is ineffective, the pericardium is usually removed surgically.

When acute pericarditis occurs within the first few hours or days of a heart attack, treatment for the heart attack, including aspirin and stronger analgesics such as morphine, can usually reduce any discomfort due to pericarditis.

The prognosis for people who have pericarditis depends on the cause. When pericarditis is caused by a virus or when the cause is not apparent, recovery usually takes 1 to 3 weeks. Complications or recurrences can slow recovery. People with cancer that has invaded the pericardium rarely survive beyond 12 to 18 months.