Pericarditis: Understanding a Diagnosis

Pericarditis is inflammation or irritation of the pericardium, the thin, elastic sac covering the heart. The cardinal symptom of pericarditis is sudden, sharp chest pain that worsens when taking a breath and when lying down.

While treatable and generally not considered dangerous, pericarditis can mimic potentially life-threatening conditions like a heart attack. It is crucial to see a healthcare provider immediately to evaluate the cause of the pain.

This article will provide an overview of pericarditis, including what it feels like, possible causes, diagnosis, and treatment. It will also explore pericarditis prognosis and what happens when episodes recur.

Pericarditis, Inflammation, and Chest Pain

The pericardium encloses the heart and comprises two thin layers of tissue with a small fluid-filled space between them.

The purpose of the pericardium is to stabilize and fix the heart's position within the chest. It also serves as a physical barrier, minimizing friction with nearby structures, like the lung, and preventing infection spread from those structures. 

Sharp chest pain is the principal symptom of an inflamed pericardium, of which there are several possible causes.

What Causes Pericarditis?

Pericarditis can manifest in people of any sex and at any age, although it's most common in males between the ages of 16 and 65.

Pericarditis causes include:

• Infection from a virus (most common), bacteria (e.g., tuberculosis), and, very rarely, a parasite or fungus
  
• Chest trauma/post-cardiac injury—for example, from a car accident, heart-related surgery, or heart attack
• Metabolic disorders, including kidney failure and an underactive thyroid gland (hypothyroidism)
• Prior chest radiation—for example, as part of treatment for lung cancer
• Cancer metastasis (spread) to the heart
• Autoimmune diseases, such as lupus, rheumatoid arthritis, and scleroderma
  
• Medications —for example, the chemotherapy drug Adriamycin (doxorubicin), heart medicines Apresoline (hydralazine) and Pronestyl (procainamide), and blood-thinning drugs warfarin and heparin
  

In an estimated 85% of cases, the cause of a person's pericarditis remains unknown and is termed "idiopathic." In such scenarios, healthcare providers typically presume the culprit to be a viral infection.

How Pericarditis Feels

Pericarditis most frequently causes a rapid onset of sharp or stabbing chest pain that worsens with breathing and coughing and improves when sitting up or leaning forward.

Less commonly, pericarditis causes a dull or throbbing pain in the chest that radiates (travels or spreads) to the left shoulder and neck area.

The chest pain of pericarditis can be accompanied by shortness of breath (dyspnea) and a mild fever.

Types of Pericarditis

The different types of pericarditis are:

• Acute pericarditis manifests suddenly and lasts less than four to six weeks.
• Incessant pericarditis is acute pericarditis that lasts more than four to six weeks without an interval of symptom recovery.
• Recurrent pericarditis is when new symptoms of acute pericarditis develop after a symptom-free period of four to six weeks.
• Chronic pericarditis is when the signs and symptoms of pericarditis develop over time and last more than three months.
• Constrictive pericarditis is when a chronically inflamed pericardium thickens and stiffens due to scarring, preventing the heart from filling and functioning correctly.

Pericarditis Prognosis

Pericarditis is a reasonably common condition, accounting for an estimated 0.1% of people hospitalized for chest pain and 5% of cases of chest pain seen in the emergency room for chest pain not caused by heart attack.

The condition is generally considered benign (harmless), although the disease can recur, and symptoms can be challenging to control. Moreover, there is a rare risk of cardiac tamponade developing.

Cardiac tamponade is a medical emergency that occurs when excess fluid within the pericardium (pericardial effusion) dangerously squeezes the heart muscle, impairing its function.

Other markers of a more severe illness and poorer prognosis include:

• Fever
• Presence of large pericardial effusion
• Lack of response to treatment after one week
• Subacute onset (when pericarditis symptoms gradually develop over weeks or months)

Pericarditis Treatment

A nonsteroidal anti-inflammatory drug (NSAID), such as aspirin, Advil and Motrin (ibuprofen), or Indocin (indomethacin), is the cornerstone treatment of acute pericarditis.

Another anti-inflammatory medication, colchicine, is often given in combination with an NSAID. Besides alleviating symptoms, research has found that colchicine reduces the likelihood of pericarditis recurring.

If NSAIDs and colchicine cannot be taken or are not effective or tolerated, corticosteroids ("steroids") may be prescribed.

Besides anti-inflammatory treatments, the underlying cause of the pericarditis must be addressed. For example, bacterial pericarditis requires treatment with one or more antibiotics.

Likewise, a person with lupus-related pericarditis may take the disease-modifying antirheumatic drug (DMARD) Plaquenil (hydroxychloroquine) and steroids in addition to NSAIDs.

Complications

For significant pericardial effusions or for cardiac tamponade, an invasive procedure called a pericardiocentesis is performed.

During a pericardiocentesis, a needle is typically inserted into the pericardial cavity under the guidance of an ultrasound (echocardiogram) or an X-ray imaging technique (fluoroscopy). The fluid is then drained out through a thin tube called a catheter.

While pericardiocentesis is the preferred treatment for draining excess fluid from the pericardium, a surgical technique—pericardial window—may be performed in select cases (e.g., individuals with recurrent pericardial effusion or effusion with cancer cells).

During this open-heart surgery, a surgeon makes incisions in the chest to visualize and remove a small portion (a window) of the pericardium, allowing fluids to be sucked or drained out.

Hospitalization

Most people with pericarditis can be treated at home under the guidance of a healthcare provider.

Features that can help identify who should be hospitalized for their care include individuals with:

• Fever greater than 100.4 degrees F
• Persistence of pericarditis, despite taking an NSAID
• Large pericardial effusion
• Cardiac tamponade (medical emergency)

Managing Chronic Pericarditis

Around 15% to 30% of people with acute pericarditis develop recurrent episodes, or their disease evolves into incessant or chronic pericarditis.

The risk of developing recurrent or chronic pericarditis is lower in people with idiopathic pericarditis and in those who took colchicine to treat the initial episode.

Inadequate treatment regimens regarding drug duration or dose, for example, can also impact the likelihood of recurrent pericarditis episodes.

In cases of recurrent pericarditis, NSAIDs and colchicine are usually tried first. Steroids may also be given in select cases.

Interleukin 1 (IL-1) blockers, namely Kineret (anakinra) and Arcalyst (rilonacept), are also sometimes given, either concurrently or if the above medications are not effective. IL-1 is a specific cytokine, a protein that regulates inflammatory responses in the body.

As a last resort, or in cases of constrictive pericarditis, a surgical procedure called a pericardiectomy may be performed. This operation entails removing part or most of the pericardium.

How Do Providers Diagnose Pericarditis?

Healthcare providers diagnose pericarditis by considering a person's symptoms, findings from a physical examination, and results from laboratory and imaging tests.

Medical History and Physical Exam

When evaluating for possible pericarditis, a healthcare provider will inquire about symptoms, medications, and past and current health conditions, like cancer or a prior viral infection.

During the physical exam, after vital signs (temperature, heart rate, blood pressure, breathing rate) are taken, the healthcare provider listens to the heart with a stethoscope.

Findings may include:

• A fast heartbeat (tachycardia)
• A low-grade fever
• A pericardial friction rub—an abnormal scratching or grating heart sound caused by the two inflamed tissues of the pericardium rubbing together

Findings based on the underlying cause may also be revealed during the medical history and physical exam.

For example, a rash or joint swelling may be seen with an autoimmune disease like lupus or rheumatoid arthritis, whereas weight loss and night sweats may be reported in a person with tuberculosis.

Imaging Tests

The imaging tests used to help diagnose pericarditis are:

• A chest X-ray is usually the first imaging test ordered for a person with possible pericarditis. If a pericardial effusion is present, the heart looks like a boot, known as the "water bottle sign."
• An electrocardiogram (ECG or EKG) measures the heart's electrical activity and reveals characteristic findings in pericarditis.
• An echocardiogram uses sound waves to visualize the heart and can detect pericardial effusion and help determine if cardiac tamponade is occurring.
• Cardiac magnetic resonance imaging (MRI) produces three-dimensional (3D) images of the heart using magnetic fields and radio waves (not radiation). This imaging test is useful if echocardiogram findings are inconclusive.

Other Tests

An elevated inflammatory blood marker—C-reactive protein (CRP)—can support a pericarditis diagnosis.

CRP levels can also be followed as a person is being treated for pericarditis to monitor their response and assess their risk for developing complications or recurrent episodes.

Finally, if a pericardial effusion is present, and the cause is suspected to be infectious (other than viral) or cancerous, the drained fluid may be examined under a microscope by a pathologist (a physician specializing in evaluating body tissues/cells) for diagnostic purposes.

How to Support Heart Health With Pericarditis

If you or a loved one has been diagnosed with pericarditis, know that most people recover well with rest and treatment, although it can take a month or longer. While recovering, take the medication your healthcare provider prescribes and attend your follow-up appointments as directed.

Also, ask your provider about specific exercise and sleep instructions. For example, your provider may recommend sleeping in an elevated position to minimize chest discomfort.

Regarding physical activity, exercise is generally restricted in nonathletes until symptoms resolve and clinical markers (e.g., CRP level) return to normal. For athletes, at least three months of exercise restriction is often advised.

In addition, even though there is no surefire way to prevent initial or recurrent episodes of pericarditis, you can maximize your chances by doing the following:

• Avoid potential chest injuries (e.g., wearing a seatbelt)
• Prevent infection by washing your hands frequently and maintaining updated vaccinations
  

Summary

Pericarditis is irritation of the pericardium, the sac covering the heart. Its hallmark symptom is sharp chest pain that worsens when taking a deep breath and improves when leaning forward. Potential causes include a viral infection, autoimmune disease, cancer, or chest trauma.

While not considered dangerous (unless a rare complication called cardiac tamponade develops), pericarditis can mimic life-threatening conditions like a heart attack. A prompt diagnosis through a physical exam, blood tests, electrocardiogram, and imaging tests, namely an echocardiogram, is essential.

Treatment of pericarditis aims to ease chest pain and inflammation and often includes taking an NSAID, colchicine, or some combination. Invasive procedures like a pericardiocentesis to drain fluid around the heart or, rarely, a pericardiectomy to remove part or all of the pericardium may also be performed.