Pericarditis is a disorder in which inflammation of the pericardium occurs. The pericardium is a sac or membrane-like structure comprising two thin layers of tissue around the heart. The function of the pericardium is to protect and lubricate the heart and keep it in its position; the pericardium also ensures the proper functioning of the heart, The space between the two thin layers is filled with fluid to avoid friction while the heartbeats. Therefore, these two layers move against each other without any irritation. The primary sign of pericarditis is chest pain as pericardium inflammation causes rubbing the pericardium against the heart. The pain can be similar to the pain felt in a heart attack. Pericarditis can be acute (lasts for a shorter period) or chronic (lasts for longer, i.e., it develops over time). Both acute and chronic pericarditis impair the heart’s functioning. Rarely, pericarditis can lead to serious consequences, including abnormal heart rhythm and/or death. In most cases, mild pericarditis occurs, which subsides on its own with rest or primary treatment. Men between 16 years to 65 years of age are at a higher risk of contracting pericarditis. Early diagnosis of pericarditis can prevent further complications.[1,2]
Acute pericarditis: This type is further divided into acute fibrinous pericarditis and acute purulent pericarditis. In acute fibrinous pericarditis, a layer of material called fibrin covers the inflamed pericardium. In acute purulent pericarditis, the pericardium gets infected and covered with pus cells.
Chronic pericarditis: It is of two types: chronic effusive pericarditis and chronic constrictive pericarditis. Chronic pericarditis lasts for more than 3 months. Chronic effusive pericarditis is generally caused by long-lasting infections such as tuberculosis. This leads to fluid formation around the heart called pericardial effusion. Chronic constrictive pericarditis is an inflammatory process, generally characterised by fibrosis, chronic scarring, and calcification of the pericardium. This process is often associated with diastolic dysfunction that eventually leads to poor heart function and/or heart failure.
Dressler’s syndrome: It is a delayed form of pericarditis and is triggered by the immune response to an injury. It may happen a few weeks after having a heart attack, a traumatic injury to the heart, or heart surgery.
Symptoms
Below are the symptoms of pericarditis:[2-4]
High-grade temperature
Sweating
Chills
Breathing problems
Dry cough
Heart palpitations
Flu-like symptoms like fatigue, fever, weakness
Abdominal swelling
Abnormal heart rhythms, tachycardia (such as accelerated heartbeat)
Intense and sharp chest pains
Pain in the chest radiating into the left arm and shoulder, feeling better leaning forward or sitting
Intensification in pain on coughing, swallowing, taking deep breaths or lying flat
Leg swelling
Anxiety or fatigue
Swelling in your legs, feet, and ankles. This occurs mainly in the case of constrictive pericarditis.
Water retention
Heart palpitations
Causes And Risk Factors
Causes
Below are the two major types of causes:[1,4]
Infectious causes:
Viral infection: Epstein-Barr, influenza, human immunodeficiency virus, echovirus, hepatitis, adenovirus, cytomegalovirus, mumps, varicella, rubella, parvovirus, human herpesvirus, coxsackie are the most frequent reasons for viral infections.
Bacterial infection: Mycobacterium tuberculosis, streptococcus, staphylococcus, Coxiella burnetii, legionella, salmonella, pneumococcus, and Haemophilus cause bacterial infections. Except for Mycobacterium tuberculosis, other reasons are rare.
Fungal infections: Candidiasis, histoplasmosis, aspergillosis, and blastomycosis cause fungal infections. Fungal diseases are rare causes.
Parasitic infections: Toxoplasma and echinococcus etc cause parasitic infections.
Non-infectious causes:
Certain types of cancers, including blood cancer, breast cancer, lung cancer, lymphoma and melanoma
Hypothyroidism, hypercholesterolaemia, renal failure, gout, and anorexia nervosa
Heart surgery, Dressler's syndrome, and aortic dissection.
Certain medicines, such as phenytoin (taken to treat seizures), warfarin and heparin (medicines for blood thinning), and procainamide (a medicine for irregular heartbeats) (Are rare causes.)
Risk Factors
Below are the risk factors that can increase the chances of pericarditis:[6]
A previous heart attack
Autoimmune diseases
Injury and trauma from an accident
Certain bacterial, fungal and viral infections
Kidney failure
Prevention
Pericarditis cannot be prevented. However, treating the primary causes may reduce the chances of getting pericarditis.[3]
Diagnosis
Major clues for pericarditis are intense pain in the chest and backside of the shoulders and difficulty in breathing. Whenever you feel these symptoms, visit your physician immediately.
A physician makes the diagnosis of pericarditis based on various factors, including medical history and physical examinations. In the case of pericarditis, your physician tries to hear a grating or scratchy noise due to pericardial rubs with the help of a stethoscope. The noise comes from a defined area of the heart. But the noise position can be changed by leaning forward and holding your breath and you may feel better.
Following tests are performed to diagnose pericarditis:[2,4]
Blood tests and testing of the pericardium fluids provide a physician with a lot of information, including whether a person has a heart attack or not, whether the heart is functioning well or not, and the reason for pericarditis. When a person has pericarditis, his/her C-reactive protein levels and sedimentation rate are higher than the normal ones.
A cardiac catheterization gives information on the pressure filling in the heart. This test is used as a confirmatory test for constrictive pericarditis.
A chest x-ray is done to detect fluid in your lungs and the size of your heart.
The electrocardiogram helps observe changes in the heart rhythm. Half of the patients having pericarditis have a heart rhythm that goes through a sequence of 4 different patterns. It is possible that some patients have no changes.
The echocardiogram is done to look at how the heart is functioning. It also checks the pericardial effusion or fluid around the heart. An echocardiogram shows the primary signs of constrictive pericarditis, including a thick or stiff pericardium that disturbs the normal heart functioning.
Cardiac computed tomography helps detect fluid, tumours, inflammation, calcium in the pericardium, and disease in the regions around the heart. During this test, iodine dye is used to collect more information on inflammation. This is a significant test for the patients for whom surgery for constrictive pericarditis is needed.
Cardiac magnetic resonance imaging is done to look for pericardial inflammation or thickening, extra fluid in the pericardium, or compression of the heart. A chemical agent, gadolinium, is used to perform this specialized test.
Treatment
Generally, pericarditis is mild and goes away easily. Physicians may recommend medications such as ibuprofen or aspirin for pain and inflammation.
Antibiotic or antifungal medications can also be prescribed for an infection. When ibuprofen is needed in high doses, the physician advises you to take other medications to relieve gastrointestinal symptoms.
When someone has recurrent pericarditis or chronic pericarditis, colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs) can be prescribed for several years. The patient may be advised to visit the physician regularly for medical check-ups.
A diuretic is given to the patients with constrictive pericarditis that generally helps get rid of the excessive fluid.
If the symptoms do not go away after 2 weeks of treatment, or go away and then return, a physician generally prescribes colchicine. Colchicine is helpful in controlling the inflammation and preventing pericarditis from reoccurring weeks or even months later.
Other treatments, including oral or intravenous steroids, can also be prescribed. Other Anti-inflammatory medications can be given in some cases.[4,6]
Complications
Below are some of the serious complications of pericarditis:[3]
Cardiac tamponade: In this condition, fluid forms between the two membranes of the pericardium. The heart gets compressed and is not able to function properly. This can be fatal and, therefore, requires immediate attention.
Abscess: Pus builds up either in the pericardium or within the heart.
Infection spread: The infection can spread to other body parts.
Constrictive pericarditis: Inflammation scars the pericardium and scar tissues do not stretch. Therefore, the heart does not function well.
Alternative Treatments
In most cases, medications are the only treatment for patients with pericarditis. However, in some cases, fluid forms in the pericardium and causes compression of the heart. Then below surgical procedures are recommended, though surgery is only recommended when all other treatments do not work.[4,6]
Pericardiocentesis: A thin, long tube called a catheter is inserted into the heart for removing fluid from the pericardium. Echocardiography is used to guide the catheter and a needle into the pericardium. In case pericardiocentesis fails to drain the extra fluid, a surgical method called a pericardial window is used.
Pericardiectomy: In the case of constrictive pericarditis, pericardectomy is performed, in which some part of the pericardium is removed entirely. This procedure is done in the case of extremely severe conditions.
References
1. What is Pericarditis? American Heart Association. Available at: https://www.heart.org/en/health-topics/pericarditis/what-is-pericarditis. Last accessed: 21 July 2021
2. Pericarditis. Heart&Stroke. Available at: https://www.heartandstroke.ca/heart-disease/conditions/pericarditis. Last accessed: 21 July 2021
3. Pericarditis. Better Health Channel. Available at: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pericarditis. Last accessed: 21 July 2021
4. Pericarditis. Cleveland Clinic. Available at: https://my.clevelandclinic.org/health/diseases/17353-pericarditis. Last accessed: 21 July
5. Diagnosis of acute pericarditis. European Society of Cardiology. https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-Last accessed: 21 July 2021 6. Pericarditis. Aurora Health Care. https://www.aurorahealthcare.org/services/heart-Last accessed: 21 July 2021
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