Monday, March 8, 2010 – Noon
Allan Klein, MD
Director of Cardiovascular Imaging Research and a staff cardiologist in the Section of Cardiovascular Imaging
Pericarditis is an inflammation of the pericardium and most cases of pericarditis occur in men aged 20 to 50, but it can also occur in women. It usually develops suddenly and may last up to several months. Sometimes excess fluid develops in the space between the pericardial layers and causes a buildup of excess fluid around the heart and if left untreated it can be life-threatening. Dr. Klein, Director of the Center for Diagnosis and Treatment of Pericardial Diseases and Director of Cardiovascular Imaging Research answers your questions about pericarditis as well as other pericardial diseases.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Allan Klein. We are thrilled to have Dr. Klein here today for this chat. Thank you for joining us Dr. Klein. Let’s begin with the questions.
Speaker_-_Dr__Allan_Klein: Thanks for having me.
bryson: I have been diagnosed as having pericarditis. I was initially hospitalized when the symptoms manifested. Now I don't go in but just get through it. Will it ever go away? It seems to recycle every six months. Is it curable?
Speaker_-_Dr__Allan_Klein: Pericarditis is often self limited. But - can be recurrent in around 30 percent of the time. Often it has to be controlled with medicines and it can burn itself out over many years. Note that this is a fairly benign disease but it can be disabling.
flores21: I have had 5 attacks of pericarditis. My doctors cannot figure out why it keeps coming back. I have been on colchicine and many pain meds. Any suggestions? Any thoughts regarding why this keeps happening?
Speaker_-_Dr__Allan_Klein: The first thing is to establish that it is truly recurrent pericarditis. We often use markers of inflammation such as CRP and sed rate - as well cardiac MRI to assess the degree of inflammation.
Speaker_-_Dr__Allan_Klein: Pericarditis is often recurrent in 30 % of the time; it is usually a benign disease and will eventually disappear over several years.
frankem: What defines "recurrent" pericarditis? For example, if you have more than one episode over the course of one year, is that considered "recurrent pericarditis"?
Speaker_-_Dr__Allan_Klein: Recurrent pericarditis is in two forms. One is if it recurs only when you stop the medicines - or comes and goes without any medicines. Having more than one episode over a year could be considered recurrent. Often recurrent pericarditis has to be treated with anti-inflammatory medications to keep the inflammation under check. Eventually the recurrent pericarditis will burn itself out after several years.
dwlogan: I am a 37 yo male American expatriate in Egypt that has been experiencing recurrent (mostly continuous) idiopathic pericarditis for about two years now with no explanation. I'm prescribed indomethacin 50mg t.i.d. I'd like to figure this out, but I'm uncertain of the advice I'm getting from the local doctors. What should I pursue next???
Speaker_-_Dr__Allan_Klein: It sounds like you have recurrent pericarditis. The most common cause is viral. The goal of therapy is to keep the inflammation under check with a non-steroid anti-inflammatory such as indomethacin. We often prescribe ibuprofen 800 mg 3 times a day instead of indomethacin. If this does not work, we often add another medication called colchicine. Unfortunately, you have to be on these medications to keep the inflammation under check and lessen the severity of the recurrences. Rest assured, this is a benign condition and it will eventually disappear.
If you are interested, we have a service called eClevelandClinic that offers online second opinions. I would suggest Dr. Griffin as he is part of the Pericardial Center. http://www.eclevelandclinic.org/
thomasutv3: Is it possible to have pericarditis over 6 years on and off? are there diet or exercise regimens you can do to prevent it from re-occurring?
Speaker_-_Dr__Allan_Klein: It is not uncommon to have recurrent pericarditis over a 5 to 10 year period. Unfortunately, diet and exercise does not really affect the recurrence rate. A goal of therapy would be to keep the symptoms under check. A healthy diet and exercise are good things and should be encouraged.
rose5654: My doctor told me I have chronic pericarditis - can you talk about what that is?
Speaker_-_Dr__Allan_Klein: Chronic pericarditis means that it lasts more than 3 months - it would be important to establish whether this is recurrent pericarditis or constrictive pericarditis because there are many syndromes.
DLBlum: I am a male, 56 yrs. old and live in California. I had a biopsy Oct. 2008 and have Constrictive Pericarditis. They doctors have determined that the only remedy is surgery. I'm in good health, no smoking, not over weight, blood pressure is 120/80 with medication, cholesterol around 145 on medication. We are on a risk vs. reward basis for having surgery to correct the condition. I don't like my quality of life and my condition is slowly getting worse. What would you recommend given this information? I'm thinking I should have surgery sooner than later while I'm healthy and still able to function vs. waiting till my breathing gets so bad that I'm not able to function at all. I do get short of breath if I try doing any manual labor or heavy lifting. Does Cleveland work with Kaiser Health?
Speaker_-_Dr__Allan_Klein: Constrictive Pericarditis is most often treated with surgery. However, it is important to see how advanced the constriction is based on clinical, hemodynamic and imaging tests. If the constriction is not too severe, it can be treated often with medical therapy such as diuretics. However, if there is significant shortness of breath, swelling of the ankles, then often this needs to be treated with surgery. Cleveland Clinic does have an affiliation with Kaiser - but you should definitely check with your individual insurance plan. This is one of my specialties - I would be glad to see you.
Danny: Thanks much for your great and informative web site. I have been diagnosed for constrictive pericarditis and am seeing a cardiologist here in So. California for it. This was discovered during a quadruple bypass May of '09 and is still an issue. I'm hoping that it will not require major surgery, but that will be determined mid April. One question is that while reading your information it mentioned viral infection can be a cause for this infection, and I have Hepatitas-C something I brought home from combat in Vietnam in 1967, and am just curious if that could have helped to cause the constrictive peracarditis. I would like to thank you in advance for any information about this.
Speaker_-_Dr__Allan_Klein: Constrictive pericarditis is most likely caused by viral syndromes that you may have had many years earlier. Often from a flu-like illness. Hepatitis C is possible but a very uncommon cause. The other causes often include previous cardiac surgery or radiation - which you don't have.
We see people with constrictive pericarditis all the time at the Cleveland Clinic - it would be important for you to go to a big center to evaluate if you need surgery. We do 30 - 40 pericardiectomies per year here.
tim: I have constrictive pericarditis. I have shortness of breath, swelling in the legs and feet and chest pain all the time. I am concerned - what are the treatments of this?
Speaker_-_Dr__Allan_Klein: The treatment for constrictive pericarditis is most likely surgery particularly if there is shortness of breath or ankle swelling. We use a constellation of clinical examination, imaging tests including echo/TEE (transesophageal echo) ct/mri to see how severe the constrictive pericarditis is before recommendations of surgery.
DLBlum: Thanks for your response. It's being treated with a diuretic but do have the other symptoms. How often do you perform this type of surgery as it seems that no one really lists it as a specialty?
Speaker_-_Dr__Allan_Klein: There are 40 pericardiectomies a year at the Cleveland Clinic - the surgeons recommended here would be Dr. Lytle, Dr. Johnston, or Dr. Pettersson.
DLBlum: In the biopsy they measured the thickness at 3 mm. How would you rate that in terms of severity?
Speaker_-_Dr__Allan_Klein: The biopsy did show some increased thickness of the pericardium however this does not establish how severe the pericarditis is. This often relates to the clinical presentation of ankle swelling, shortness of breath, abnormal imaging tests and abnormal hemodynamics by heart cath.
DLBlum: Thanks so much for this forum. It's been great to be able to ask questions and get your responses. We may be talking in the future. Thanks again
Speaker_-_Dr__Allan_Klein: You’re welcome - please call my office if you would like a referral. 216-444-3933 or 800-223-2273, extension 43933. We see your type of condition 2 - 3 times a week and are happy to see you.
Post Pericardiotomy Syndrome
March2010: I have had a triple by-pass, two medicated stents and a pacemaker. I started with an aorta repair I believe some valve work, and angiography. I believe I am starting with pericardial problems as I have a friction sound and shortness of breath. I feel that doctors need to be more straight forward about why we should eat fruit and vegetables and let us know what is in store. I am on coreg 6.25 twice a day. When it was doubled from 3.12 I questioned it and was later told to double it again. I felt it was a miscommunication-I tried and had problems so pulled back. Later other doctors agreed because my blood pressure was low and agreed to keep me on the 6.25. Was this the start of pericardial effusion? Should I have doubled it again or gone to 9.50 or so. What can I do about a beginning friction? I fell about this time and have various bruising and a hematoma on my breast.
Speaker_-_Dr__Allan_Klein: It is not uncommon to have a pericardial effusion after heart surgery - this is called the post pericardiotomy syndrome. This has to be treated often with medicine, rarely with pericardiocentesis if it is large enough. Symptoms of pericardial effusion can include shortness of breath, low blood pressure and fast heart rates. If you have any of these you probably need an echocardiogram to assess the severity and size of pericardial effusion.
kgageorgia: I had mitral valve repair Robotic in Nov. 5 weeks postop I developed pericarditis? I am told that in my case it will reoccur. I am 49 years old, not over weight, no high blood pressure or cholesterol. I have been on 3 rounds of prednisone and nsaids. Is there anything I can do to prevent it from coming back?
Speaker_-_Dr__Allan_Klein: You may need three medications to control your pericarditis - 1. ibuprofen, 2. colchicine and 3. tapering doses of prednisone. This whole process may take months to resolve.
jensmith: Last year I had a bovine pericardial valve placed with an episode of pericarditis occurring three times since my original occurrence. My doctor put me on a 5 month course of colchicine. I am worried why I keep having these occurrences and why this occurred after my surgery. Will it ever go away?
Speaker_-_Dr__Allan_Klein: You have a post pericardiotomy syndrome, which is not uncommon after heart surgery. You should be treated with a combination of NSAIDs (non-steroidal anti-inflammatory drugs) and colchicine. If this does not do the trick, you may need a tapering course of prednisone. It often comes on after open heart surgery because part of the surgery involves cutting the pericardium.
Symptoms of Pericarditis
wysiwyg: For 2 months, I have had chest/back pain on my left side. I looked online and think from looking up symptoms that it is pericarditis. How bad is that?
Speaker_-_Dr__Allan_Klein: First of all - there are many causes of chest pain - including pericarditis. The symptoms of pericarditis are often sharp pains in the chest - worse with breathing.
The pain often radiates to the left shoulder. Often the patient cannot lie flat on the back and has to sit upright. It can be related to a previous viral syndrome. Other things to rule out would be coronary artery disease, Gastro-esophageal reflux or ulcer, or neuromuscular pain. You should be evaluated by your doctor.
mj_007: Past two years I had pericarditis three times. What causes that? Could I have some type of autoimmune disease?
Speaker_-_Dr__Allan_Klein: Autoimmune diseases can be associated with pericarditis - such as SLE or rheumatoid arthritis. It would be important to establish whether you have these conditions. With these conditions you could have pericarditis. In this case, you should treat the underlying condition, and the pericarditis is secondary.
jasonb: What are the most common causes of pericarditis?
Speaker_-_Dr__Allan_Klein: The most common cause is viral. The scenario would be someone who has flu - like illness and several months later they have symptoms of chest pain when taking a deep breath, pain radiating to the left shoulder, abnormal EKG and abnormal echocardiogram.
Less common causes will include bacterial infection, kidney failure, heart attack, rheumatic conditions (such as lupus, rheumatoid arthritis), trauma, previous surgery, hypothyroidism - or any recent surgical devices put in the heart such as pacemaker, radiofrequency ablation of the heart.
carolbee: Hi, my 17 year old son was just diagnosed with pericarditis. What could cause that? He is very healthy but then started having bad pain in his chest and shortness of breath - will this affect him long term or can he go back to his normal activities when the symptoms go away.
Speaker_-_Dr__Allan_Klein: If it is pericarditis, it is most likely from a viral cause. This eventually should disappear on its own but may need anti-inflammatory medications, such as ibuprofen. In 1/3 of the cases, it can become recurrent. If it is pericarditis, the activities have to be curtailed and treated. Once he has been treated on the medicines, he can resume some of his activities.
Medications for Pericarditis
PatriciaB: Pericarditis: I am 9 weeks postop pacemaker/lead replacement which resulted in occluded subclavian (on coumadin) and pericarditis. (Was very healthy and active prior) Currently I am on my 3rd round of prednisone for pericaridits-2 weeks tapered each time. I have never resolved the pericarditis-symptoms immediately come back after drug therapy. NSAIDs (non-steroidal anti-inflammatory drugs) alone not effective. Would it still be beneficial to start NSAID and Cholchicine immediately after finishing this taper of Prednisone?
Speaker_-_Dr__Allan_Klein: For your pericarditis after pacemaker/lead replacement, you should be on all three medicines while you are tapering your prednisone - this includes ibuprofen, colchicine and prednisone. The prednisone should be tapered very slowly - over weeks to months. Once that is stopped - you have to continue the ibuprofen and colchicine - then you can begin tapering off the ibuprofen and then last, the colchicine - this may take many months.
kgageorgia: What is Colchicine?
Speaker_-_Dr__Allan_Klein: Colchicine is a benign medicine - it has been around over 50 years. It is an anti-inflammatory that is used to treat often older men with gout. The major side effect with colchicine can be gastro in nature. It seems to help recurrent pericarditis.
frankem: Is there a difference in the way you would treat "recurrent pericarditis" vs. acute pericarditis?
Speaker_-_Dr__Allan_Klein: Yes - acute pericarditis can be very self limited and just be treated with a non-steroidal such as ibuprofen. Recurrent pericarditis is more often treated with multiple medicines including ibuprofen or naprosyn, colchicine and rarely prednisone.
DLBlum: What kind of success rate has the clinic had over time after performing Pericardiectomy? What are the risks associated with this surgery?
Speaker_-_Dr__Allan_Klein: The results of pericardiectomy at Cleveland Clinic are generally good - often related to the cause - why you got the pericarditis in the first place. If you got it from a viral cause - or unknown cause - the results are generally good. If is from previous cardiac surgery - then this is a higher risk surgery.
babygirl00: I am 22 years old and have had chest pain on and off for over a year. My doctor recently diagnosed me with constrictive pericarditis. My doctor said I need a pericardiectomy. Can you tell me more about this procedure and how it will treat my condition? Will my symptoms go away?
Speaker_-_Dr__Allan_Klein: Pericardiectomy is rarely performed for chest pains. It is most often done if there is a thickened lining around the heart and for symptoms of leg swelling and shortness of breath. If there are chest pains - you may need a good course of anti-inflammatory medications.
Pericardiectomy is a surgical procedure, where they remove most of the thickened lining around the heart. This helps relieve any compression of the heart by the thickened lining. In general most people at Cleveland Clinic do very well with the surgery and we would be glad to evaluate for this problem. We have a multidisciplinary Pericardial Center set up at the Cleveland Clinic to evaluate patients like yourself.
sandra: My husband has been diagnosed with constrictive pericarditis and will need a pericardiectomy - how long is that surgery? Can they do it robotically?
Speaker_-_Dr__Allan_Klein: Pericardiectomy for constrictive pericarditis is often done at the Cleveland Clinic with around 40 cases per year. In most often involves a sternotomy (incision) rather than robotic surgery to remove most of the lining of the pericardium. Surgery takes several hours. We have strong expertise for this problem at Cleveland Clinic.
DLBlum: If we came from out of state for surgery how long would I expect to stay at the clinic before returning to Calif. & would my local cardiologists be able to do follow up exams?
Speaker_-_Dr__Allan_Klein: Most of our patients are from out of state and usually the surgery stay would be between 4 - 7 days. You can return back to California and have follow up with your cardiologist after surgery. Follow up is generally 4 - 6 weeks after surgery.
jacobs_addie: I am 36 years old and had an echo and stress test and all came out normal except pericardial effusion. What would cause that? I am worried. I read online it can be related to cancer? What is the occurrence of that?
Speaker_-_Dr__Allan_Klein: The most common cause of pericardial effusion is not cancer - it is most likely viral. It depends on how large the pericardial effusion is before any further testing is necessary.
sammy: I am 38 years old. I just had an echo and it showed aortic regurgitation and small pericardial effusion. Is the pericardial effusion related to the aortic valve/
Speaker_-_Dr__Allan_Klein: The pericardial effusion can be related to the aortic valve if there is evidence of congestive heart failure.
carringtonm: My wife had an echocardiogram and it showed that he had fluid around the heart. What does that mean - is that pericarditis?
Speaker_-_Dr__Allan_Klein: Fluid around the heart is called pericardial effusion. It can be related to previous pericarditis or from other causes. It depends on how large the pericardial effusion is. IF it is very large or causing some compression, we will often remove the fluid with a small needle. If the fluid collection is very small, we will often follow this with repeat echocardiograms.
The key thing is to make sure that the cause of the effusion is a benign cause. And - also make sure that the effusion is not large in severity.
SHE-SHE: I HAVE A PERICARDIAL CYST, LEFT SIDE, 3CM. MY CARDIO DOC BLEW IT OFF. I HAVE MOST OF THE SYMPTOMS LISTED IN YR INFO. SHOULD I CONTINUE SEARCHING FOR AN ANSWER? THX
Speaker_-_Dr__Allan_Klein: Pericardial cysts is most likely benign and should be followed with imaging tests - such as echocardiogram, MR/CT. Rarely the cyst can rupture and cause symptoms.
Rarely cysts can be malignant but most commonly are benign. If the cyst is getting larger in serial studies or have features of malignancy then it should be removed.
rrtw123: I had a Ct scan and my doctor told me I have a pericardial cyst. Can you tell me what that is, how serious is it and what is the treatment?
Speaker_-_Dr__Allan_Klein: A pericardial cyst is a benign condition with a very small sac of the lining of the heart with fluid. Most times this should just be followed with imaging tests.
Rarely, this has to be removed surgically if the cyst grows in size or has some features of malignancy. In general, the cysts are benign and just requires follow-up.
Other questions related to pericarditis
BlueSky27: What is pericarditis and are there natural therapies for it?
Speaker_-_Dr__Allan_Klein: Pericarditis is often related to inflammation of the heart. It can be acute or chronic. Since it is related to inflammation, the most common medical therapy would be anti-inflammatory medications. There have been no trials with natural remedies.
kellier56: I have atrial fibrillation and pericarditis. Are they related?
Speaker_-_Dr__Allan_Klein: Often they are not related - but in situations of previous open heart surgery, or radiofrequency ablation for atrial fibrillation, there can be an association. Rarely, if you have inflammation of the heart, you can have both situations.
hynes_s: I am currently 3 months pregnant and have mild restrictive pericarditis - is that common during pregnancy? what treatments can you have while pregnant?
Speaker_-_Dr__Allan_Klein: In terms of your question, it is not clear whether you have restrictive cardiomyopathy which is a diseased heart muscle or is it constrictive pericarditis which is thickened lining around the hear.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Allan Klein is now over. Thank you for joining us and thank you again Dr. Klein for taking the time to answer our questions about pericarditis.
Speaker_-_Dr__Allan_Klein: Thanks for having me today.
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