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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- 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, such as weakness, fatigue, and difficulty breathing. Cardiac tamponade may occur.
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Cardiac Tamponade: The Most Serious Complication of Pericarditis
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Cardiac tamponade is caused by accumulation of fluid or blood between the two layers of the pericardium. The accumulating fluid or blood puts pressure on the heart, interfering with its ability to pump blood. As a result, when a person breathes in, blood pressure may fall rapidly to abnormally low levels and the pulse may correspondingly weaken. When a person breathes out, blood pressure increases and the pulse becomes stronger. This exaggeration in the variation in blood pressure and pulse that occurs with breathing is called a paradoxical pulse. Later, as the heart is compressed more, the blood pressure remains low, and the person may pass out or die.
The most common causes of such significant fluid accumulation are cancer, heart injury, or heart surgery. Viral and bacterial pericardial infections and kidney failure are other common causes.
Echocardiography (which uses ultrasound waves to produce an image of the heart) may be used to confirm the diagnosis. This procedure can detect characteristic changes, such as compression of the heart and the variations in blood flow in the heart that occur with breathing.
Cardiac tamponade is usually a medical emergency. Doctors treat it immediately by removing fluid from the pericardium using a needle or catheter inserted through the chest wall to relieve the pressure in a procedure called pericardiocentesis. When time permits, fluid removal is closely monitored using echocardiography. Fluid may be surgically drained using a balloon-tipped catheter inserted through the skin (a procedure called percutaneous balloon pericardiotomy) or using a tube inserted through a small incision in the chest (a procedure called subxiphoid limited pericardiotomy). If the cause of pericarditis is unknown, doctors may send a sample of the fluid or a piece of tissue removed from the pericardium for examination under a microscope. This examination may provide information that helps identify the cause.
After the pressure is relieved, the person is usually kept in the hospital in case cardiac tamponade recurs. The person is usually monitored for 24 hours. The length of the hospital stay depends on the cause of tamponade. If a drain is in place, the person stays in the hospital until no more drainage occurs and the drain is removed.
If cardiac tamponade recurs, the same procedures may be performed again, or a different procedure may be tried. Other procedures include injection of a solution that obliterates the pericardium by causing scar tissue to form (sclerotherapy) and removal of the pericardium (pericardiectomy).
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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 Coronary Artery Disease: Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina)). 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 Symptoms and Diagnosis of Heart and Blood Vessel Disorders: Echocardiography and Other Ultrasound Procedures) 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. 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 Pain: Nonsteroidal Anti-Inflammatory Drugs), 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 after 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.
Last full review/revision August 2006 by Brian D. Hoit, MD
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