Pericarditis is a condition that involves inflammation of the pericardium, which is the membrane that surrounds the heart. The role of the pericardium is to anchor the heart, and help prevent excessive movement in the chest due to breathing or body movement. Pericarditis is characterised by mild to severe chest pain, which often increases with deep breathing or lying flat, and is usually relieved by sitting up or leaning forward. Depending on the cause of pericarditis, individuals can also experience shortness of breath and fever.

 

Pericarditis generally occurs in men aged 20-50, and cases can range from mild symptoms which resolve spontaneously, to severe cases which require surgery. Most people recover from pericarditis in two weeks to three months, and the condition can be caused by heart attack, infection, cancer, kidney failure, immune disorders or some medications. People who have had chest trauma, open heart surgery or a heart attack are at increased risk of developing pericarditis.

 

Pericarditis is not usually a life-threatening illness, and most cases resolve without any permanent loss of cardiac function. There are three important complications that can arise, which include tamponade (accumulation of fluid), constrictive pericarditis and chronic (long term) pericarditis. Pericarditis is treated by the administration of analgesics, non-steroidal anti-inflammatory drugs and diuretics, which relive pain and treat inflammation. If fluid build-up around the heart is excessive, then drainage may be required, either by catheter or surgery.

 

 

Symptoms

 

The most common symptom associated with pericarditis is chest pain. Pain is felt by individuals predominantly below the sternum (breast bone), and also below the ribs, on the left side of the chest. Pain can also sometimes be felt in the abdomen, neck or upper back. Pain experienced by individuals suffering from pericarditis often worsens when they lie down, and improves when they sit up. This is because changes in body position can either increase or decrease the pressure on the inflamed pericardium. Pain often also worsens with heavy breathing, coughing or swallowing as theses actions cause the heart and lungs to move up and down, and rub against the inflamed pericardium. Shortness of breath, which is called dyspnea, is also a symptom associated with pericarditis. Dyspnea is caused by an accumulation of fluid between the heart and the pericardium, a space called the pericardial sac, which restricts the movement of the heart. Restricting the heart reduces blood flow and leads to shortness of breath.

 

 

Causes

 

There are many causes of pericarditis. These include:-

 

Infection

Pericarditis caused by fungal, bacterial or viral infection is called purulent pericarditis, and often occurs when respiratory, oral, or skin infections spread to the blood. Purulent pericarditis can also arise from infection after heart surgery. Patients who are immunocompromised often develop pericarditis from infection. Viral infection is usually the most common cause of pericarditis in young, otherwise healthy individuals. The most common microorganisms responsible for infections that lead to purulent pericarditis are staphylococci, streptococci, pneumococci, meningococci and Hemophilus influenzae.

 

Heart attack

Approximately 15% of individuals who have suffered a heart attack develop pericarditis. This can happen within two to five days after a heart attack or can occur up to 10 weeks later. If pericarditis occurs shortly after a heart attack, it is often due to overactivity of the immune system. The presence of blood or dead tissue in the pericardium sac triggers an immune response, which damages healthy tissue and causes inflammation. When pericarditis persists for several weeks after a heart attack it is referred to as Dressler’s syndrome. Pericarditis can also be caused by injury, trauma or surgery to the oesophagus, chest or heart.

 

Medication

Pericarditis can be caused by some medications that affect immune function. Medications such as penicillin, which is used as an antibiotic to treat bacterial infection, phenytoin, which is a seizure medication, and hydralazine, a hypertension and heart failure medicine, have been associated with pericarditis.

 

Immune disease

Pericarditis can also develop in individuals with diseases that affect the immune system such as lupus or rheumatoid arthritis. In these diseases, the immune system is overactive, and can damage healthy tissue resulting in inflammation.

 

Metastatic disease

Tumour cells from other parts of the body can metastasise (spread) to the pericardium, which can cause irritation and inflammation.

 

Radiation therapy

Radiation therapy is used to treat cancer, and when applied to the chest, can cause pericarditis.

 

Kidney failure

A build-up of toxins in the body, caused by kidney failure, can also lead to pericarditis by irritating the pericardium and causing inflammation.

 

Often, a cause for pericarditis can not be identified. In these cases, the illness is referred to idiopathic pericarditis.

 

 

Diagnosis

 

Pericarditis is diagnosed through medical history, physical examination and diagnostic tests. The physician can listen to the heart though a stethoscope to identify sounds that indicate pericarditis. For example, the heart can sound quieter than usual or muffled, or breathing sounds can be decreased or ‘crackly’. When breathing sounds are abnormal, this can also indicate that fluid is present in the space around the lungs. This condition is known as pleural effusion, and generally only develops in severe cases. Veins in the neck such as the jugular venous can be examined for elevated pressure as a sign of changes to the heart chamber and pericardial space. Purulent pericarditis is often diagnosed in conjunction with signs of pneumonia due to infection, and is confirmed when microorganisms are found in the pericardium fluid. Looking at the number and type of bacteria in the blood, and also the number of white blood cells present can help to confirm purulent pericarditis. When fluid accumulates in the pericardial sac, it can be visualised using chest x-ray and echocardiogram (ECG). These tests can reveal enlargement of the heart due to fluid collection, and any signs of inflammation. Chest x-ray and ECG can also be used to identify thickening of the pericardial wall or scarring. A tranesophageal echocardiography (TEE) can be used to measure filling patterns of the heart chambers to see if blood is returning normally to the heart.

 

Treatment

 

The pain associated with pericarditis is relieved by the administration of analgesics, which are also known as ‘pain killers’. To reduce the inflammation of the pericardium, non-steroidal anti-inflammatory drugs such as aspirin and ibuprofen are administered. Diuretics are also used to treat inflammation by removing excess fluid from the pericardium sac. Bed-rest with elevation of the top half of the body can reduce the workload on the heart. Restricting movement also minimises the pain caused by inflammation of the pericardium. Because there are many causes of pericarditis, the underlying cause must be identified to ensure the problem is resolved. For example, if pericarditis is caused by infection, then treatment may also require the administration of antibiotics or antifungal medications. If the fluid in the pericardium becomes excessive, then it may require drainage. This procedure is called pericardiocentesis, and is done either using a needle, which is inserted through the skin into the pericardial sac, or by surgical incision. A surgical procedure called pericardiectomy, which involves cutting or removing part of the pericardium, may be also recommend for pericarditis that is difficult to resolve or reoccurs regularly.

 

 

Complications

 

Pericarditis is not usually a life-threatening illness, and most cases resolve without any permanent loss of cardiac function. Pericarditis generally resolves after a few days to several weeks, but three important complications can arise. These are:-

 

Tamponade

Tamponade refers to the accumulation of fluid in the pericardial sac, preventing the heart from functioning properly. This build up of fluid prevents the heart from filling completely with blood. When this occurs, blood pressure drops, and the lungs can become congested.  The symptoms associated with tamponade are extreme dyspnea, weakness and light-headedness. Tamponade is a serious complication of pericarditis, and if left untreated, can cause death. Tamponade is treated by inserting a tiny catheter into the pericardial sac, and draining the fluid. Fluid removal relieves pressure on the heart muscle and restores cardiac function. If chronic tamponade is a problem, then surgery can be undertaken to create an opening in the pericardial sac, to allow fluid to constantly drain. Tamponade is diagnosed by ECG, which reveals changes in the size of the heart due to fluid build-up.

 

Constrictive pericarditis 

When the pericardium remains inflamed for a long period of time, the tissue can thicken, and begin to adhere to the heart muscle. This action causes the tissue surrounding the heart to become rigid, and prevents the heart muscle from contracting properly. Individuals with constrictive pericarditis can experience heart failure because the heart can not stretch and fill with blood. Constrictive pericarditis can be a hard problem to treat because the surgery to separate the pericardium from the heart is very difficult. Constrictive pericarditis is often caused by situations that lead to chronic inflammation of the pericardium, such as cardiac surgery or radiation to the chest.

 

Chronic pericarditis

Chronic pericarditis develops when pericarditis does not resolve, and the individual remains affected for long periods of time. While symptoms such as pain and inflammation can be managed, the problem is usually not resolved until the underlying cause