PERICARDITIS OVERVIEW

Pericarditis is an inflammation of the pericardium, which is the sac that surrounds the heart (figure 1). The pericardium normally functions to protect the heart and reduce friction between the heart and surrounding organs.

Pericarditis may be accompanied by pericardial effusion, which is fluid accumulation in the pericardial sac. If a large amount of fluid accumulates in the pericardium, it may squeeze or constrict the heart; this is called cardiac tamponade. Cardiac tamponade is a serious condition that can be life-threatening if not recognized and treated promptly.

PERICARDITIS CAUSES

Pericarditis has many causes, including the following:

• Unknown cause (so-called "idiopathic") — In many cases, the cause of pericardial disease cannot be determined. It is not always necessary to know the cause, especially if the condition improves with treatment.
• Infection — Any infectious organism can infect the pericardium. The majority of cases are either caused by viral infection or an unknown organism.
• Radiation — Prior radiation to the chest is an important cause of pericardial disease. Most cases are secondary to radiation therapy for malignancy, especially for breast cancer, lung cancer, or lymphoma.
• Trauma — Trauma to the chest may be blunt, as with a steering wheel injury, or sharp, as with a bullet or knife wound. Invasive cardiac procedures, and rarely, cardiopulmonary resuscitation (CPR), can cause trauma to the heart that induces pericarditis. A myocardial infarction (heart attack) injures the heart muscle due to a lack of oxygen and can cause pericarditis.
• Drugs and toxins — A number of medications can cause pericarditis.
• Metabolic disorders — The major cause of metabolic-related pericarditis is kidney failure.
• Cancerous tumors — Pericardial disease can develop when a cancer metastasizes (spreads) to the heart, most commonly from the breast, lung, or in Hodgkin lymphoma.
• Rheumatic diseases — Systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and mixed connective tissue disease are the most common rheumatic causes of pericarditis. Other possible causes include systemic vasculitides and autoinflammatory diseases (ie, Familial Mediterranean Fever).
• Gastrointestinal diseases — Pericarditis may occur in patients with inflammatory bowel disease (ulcerative colitis or Crohn's disease).

PERICARDITIS SYMPTOMS

The most common sign of acute pericarditis is chest pain, usually worsened when taking a deep breath. This pleuritic chest pain begins suddenly, is often sharp, and is felt over the front of the chest.

Dull, crushing chest pain, similar to that of a heart attack, can also occur. The pain may decrease in intensity when sitting up and may radiate around the shoulder to the upper back. Some people with pericarditis and pericardial effusion develop a fever.

PERICARDITIS DIAGNOSIS

Pericarditis is diagnosed based upon a physical examination and laboratory and imaging tests.

Physical examination — During the examination, the clinician will listen to the heart with a stethoscope. In people with pericarditis, there is often an abnormal heart sound called a pericardial friction rub. This sound is created when the inflamed pericardial layers rub against each other.

Electrocardiogram — Pericarditis and pericardial effusion produce distinctive patterns on an electrocardiogram.

Determining if pericardial effusion is present — A chest x-ray is often obtained when pericarditis is suspected. The shadow of the heart may appear enlarged if there is a large accumulation of fluid (pericardial effusion) in the pericardial sac. However, most people with sudden onset (acute) pericarditis have a normal chest x-ray since there is frequently only a small or no pericardial effusion.

An ultrasound examination of the heart (echocardiogram) is generally recommended since it is a more sensitive test for the detection of pericardial effusion. If a pericardial effusion is present, echocardiography can also help determine whether the effusion is limiting the filling of the heart (ie, causing cardiac tamponade). However, not having a pericardial effusion on the echocardiogram does not exclude the possibility of pericarditis.

Is it pericarditis? — At least two of the following four criteria are generally present in a person with pericarditis:

• Chest pain
• Pericardial friction rub (abnormal heart sound)
• ECG changes
• Pericardial effusion

Most people with pericarditis also have an elevated blood level of a substance called C-reactive protein (CRP). This protein becomes elevated as a result of the inflammatory nature of pericarditis. CRP is especially important to confirm the suspicion of pericarditis and to monitor the inflammatory disease process and its response to therapy.

PERICARDITIS TREATMENT

The goals of treatment for pericarditis include relief of pain and resolution of inflammation and effusion. Specific treatment for the cause of pericarditis may also be required. (See 'Treating the cause' below.)

Some people will be evaluated in a clinic or hospital and then treated at home while others must remain in the hospital for treatment. Admission to a hospital is generally recommended to perform diagnostic tests to exclude a specific cause that may require a targeted therapy and not simply empiric anti-inflammatory therapy or if there is an increased risk of an early complication (eg, high fever, cardiac tamponade, a large pericardial effusion, or recent treatment with anticoagulants such as warfarin (Coumadin®)).

Medication

Treatment of pain — In most patients with acute pericarditis, treatment begins with aspirin or a nonsteroidal anti-inflammatory drug (NSAID). This helps to relieve pain. If pain does not improve within one week, further evaluation and treatment are necessary. Rest is also considered an important part of the treatment in the acute phase of the disease.

Another medication, colchicine, may be recommended in addition to the NSAID. In several studies, colchicine was found to improve symptoms and reduce the risk of a future (recurrent) episode of pericarditis.

If these medications are not helpful or cannot be tolerated, a steroid (eg, prednisone) may be recommended. In most cases, the steroid dose is maintained for several days and then reduced very slowly, over a period of weeks, to reduce the risk of recurrent pericarditis.

Treating the cause — When the cause of pericarditis is identified, treatment is aimed at the underlying condition. As an example, pericarditis that is caused by a bacterial infection would be treated with one or more antibiotics. However, viral pericarditis does not require any specific antiviral treatment in most patients and is treated by empiric anti-inflammatory therapies.

Pericarditis caused by heart attack — Sometimes pericarditis and pericardial effusion occur as an early complication of a heart attack (myocardial infarction). Fortunately, the incidence of pericarditis with heart attack has sharply decreased with modern therapies that minimize the degree of heart damage. Heart attack related pericarditis is usually temporary, lasting as little as a few days.

Another type of pericarditis, known as postcardiac injury syndrome, may develop weeks or months after a heart attack, heart surgery, or other procedures on the heart. The best treatment for this condition is unclear. In different regions of the world, either aspirin or a nonsteroidal anti-inflammatory drug (eg, ibuprofen [Motrin®] or naproxen [Naprosyn®]) is preferred. Colchicine may be useful as an adjunct to another anti-inflammatory drug.

Pericardiocentesis — Pericardiocentesis is the medical term for removal of fluid from the pericardium with a thin needle. Pericardiocentesis may be recommended for some patients with pericardial effusion or cardiac tamponade (a life-threatening complication of pericardial effusion). The procedure may be useful both as a treatment and as a tool to determine the cause of pericarditis.

Risks of pericardiocentesis include bleeding, infection, and damage to the heart. The risk of these complications may be minimized when the procedure is done by an experienced clinician who performs the procedure on a regular basis.

Pericardiocentesis is usually done by inserting a needle through the skin and into the pericardial effusion. The needle is guided by ultrasound or x-ray imaging (fluoroscopy). The ultrasound or fluoroscope allows the clinician to determine where the pericardial effusion is located, helping him or her to guide the needle precisely. Less frequently, the pericardiocentesis is done by making an incision and opening the chest.

A small tube (catheter) is often left in place following pericardiocentesis to allow fluid to drain, since some fluid may remain and new fluid may continue to seep into the pericardial space. The catheter may be left in place for one to two days or more, until there is little or no new fluid drainage.

RECURRENT PERICARDITIS

Approximately 15 to 30 percent of people with sudden onset (acute) pericarditis have either recurrent or persistent disease, frequently with a pericardial effusion. This risk is reduced in people who initially take colchicine and in those without a known cause of pericarditis (idiopathic pericarditis).

Signs and symptoms of recurrent pericarditis are the same as those in the initial episode. (See 'Pericarditis symptoms' above.)

Treatment with medication — Treatment of recurrent pericarditis usually includes aspirin or a nonsteroidal anti-inflammatory drug (NSAID) and/or colchicine. In addition, further evaluation and treatment of the underlying cause is appropriate. Treatment with a steroid (eg, prednisone) may be recommended if there is no response to these initial therapies. However, the risk of recurrent pericarditis may increase with use of steroids.

Side effects of steroids may include weight gain, development or worsening of diabetes, and an increased risk of infection. Thus, when steroids are used, the goal is to use the lowest possible dose for the shortest possible time. However, the steroid dose should remain steady until symptoms have resolved and then slowly tapered to reduce the risk of further recurrences.

Pericardiectomy — Pericardiectomy is a surgical procedure that removes part or most of the pericardium, the sac that surrounds the heart. This procedure is a last resort for treatment of recurrent pericarditis due to the small potential for benefit and the larger risk of persistent pain and/or surgical complications. However, it may be recommended in some situations after all other treatments have been tried.

Coping with recurrent pericarditis — Recurrent pericarditis can be a frustrating and debilitating condition. It is important for the patient and healthcare provider to discuss the nature of the disease, the likely course, and the treatment alternatives, including the following:

• After successful treatment of a recurrence, further recurrences are possible. This process may be repeated at variable intervals for a prolonged period of as long as several years. However, the recurrences are most common in the first one to two years and tend to become less and less frequent and less severe in most cases.
• The cause of pericarditis, if known, should be discussed. If the first illness was caused by a virus, reinfection with this virus is not likely to be the cause of the recurrence. The disease eventually disappears as mysteriously as it appeared, and almost always does so with no permanent complications.
• Cardiac tamponade and constrictive pericarditis are serious but rare complications of recurrent pericarditis. Symptoms of cardiac tamponade include shortness of breath, weakness, and faintness. Symptoms of constrictive pericarditis include swelling of legs and other parts of the body (edema), fatigue, and shortness of breath.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Pericarditis in adults (The Basics)
Patient information: Pericarditis in children (The Basics)
Patient information: What can go wrong after a heart attack? (The Basics)
Patient information: Pleuritic chest pain (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

This topic currently has no corresponding Beyond the Basics content.

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Cardiac involvement in HIV-infected patients
Cardiac tamponade
Chylopericardium and cholesterol pericarditis
Constrictive pericarditis
Diagnosis and treatment of pericardial effusion
Differential diagnosis of chest pain in adults
Echocardiographic evaluation of the pericardium
Electrocardiogram in pericarditis and pericardial effusion
Etiology of pericardial disease
Clinical presentation and diagnostic evaluation of acute pericarditis
Differentiating constrictive pericarditis and restrictive cardiomyopathy
Pericardial disease associated with malignancy
Post-cardiac injury syndromes
Pericardial complications of myocardial infarction
Pericarditis in renal failure
Pulsus paradoxus in pericardial disease
Purulent pericarditis
Recurrent pericarditis
Tuberculous pericarditis

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Heart, Lung, and Blood Institute

     (www.nhlbi.nih.gov)

• American Heart Association

     (www.americanheart.org)

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