July 14, 2009
Allan Klein, MD
Director of Cardiovascular Imaging Research
Cleveland Clinic Robert and Suzanne Tomsich Department of Cardiovascular Medicine
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.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Allan Klein, MD. We are thrilled to have Dr. Klein here today for this chat. He is considered an expert in all aspects of pericardial diseases.
Speaker_-_Dr__Allan_Klein: Thank you for having me.
Pericarditis and Pericardial Disease
jamurphy: Good Afternoon Dr.Klein -Can you talk a little about Pericardial Disease and what Pericarditis is?
Speaker_-_Dr__Allan_Klein: Pericardial Disease is one aspect of heart disease affecting the lining around the heart. If you can imagine the heart is a bag and you have an outer bag around the inner bag. The outer bag is the pericardium. The purpose of this layer is to protect the heart and to provide lubrication around the heart.
Not infrequently - a viral condition, like the flu can attack this outer lining around the heart and cause inflammation and scarring. This is what we call acute pericarditis. After the damage has been done, the virus lies dormant in the lining around the heart and every few months gets reactivated and continues to cause more damage.
Over time, with anti-inflammatory medications, the pericarditis gets controlled and gradually disappears. In summary - it is a benign condition, but a recurring nuisance. Rarely, after many years, the lining can harden up and cause constrictive pericarditis, in which case surgery may be necessary. In summary pericardial diseases are usually benign and self limited.
Yang_J: If you get the flu, can it cause pericarditis?
Speaker_-_Dr__Allan_Klein: The flu is often caused by virus - many of which can attack the lining of the heart and cause pericarditis.
elesiaturn: Is it possible to have recurring episodes of acute pericarditis and have a normal echo and ekg. The episodes occur every 2 to 3 months and last about 5 to 6 weeks from beginning of symptoms to the end.
Speaker_-_Dr__Allan_Klein: You have evidence of recurrent pericarditis - this often is associated with minimal findings on the echo or EKG. It typically recurs every 2 to 3 months and unfortunately can last several years.
The key points are to keep the inflammation from the pericarditis under check with benign anti-inflammatories such as ibuprofen and colchicine.
Steven: August of 06 - Hospitalized. August of 07 ER visit, June of 08 ER visit - I was struck with pericarditis. Very scary feeling. What would case this to be an annual occurrence? I have been tested for allergies, had MRI's, EKG's nothing shows up other than the inflammation. Any comments as I sit here waiting for this years attack?!?
Speaker_-_Dr__Allan_Klein: It appears that you have recurrent pericarditis and we can expect that this pericarditis will come back every few months - which in your case, seems to have happened. It is important to be on anti-inflammatories such ibuprofen and colchicine round the clock for several months to keep the inflammation under check - even when you are feeling well.
Pink_76: I have had pericarditis 4 times. I am 35 years and have been healthy my whole life. Why does this keep happening? Will I always have this problem? Why would I get this?
Speaker_-_Dr__Allan_Klein: You have recurrent pericarditis. You mention that you had it 4 times. This is not an uncommon condition. Probably before your first episode you had a viral illness that attacked the lining of the pericardium. Every few months the virus reactivates and causes inflammation and pericarditis. Once again the key treatment is to keep the pericarditis and inflammation under check. I would reassure you that if this is the case - over time, the pericarditis will burn itself out. Unfortunately, it may take several years.
spugsie: Could you explain sed rate?
Speaker_-_Dr__Allan_Klein: Sed rate is a nonspecific marker of inflammation - it doesn't mean necessarily pericarditis, but could be elevated in any inflammatory arthritis condition, such as rheumatoid arthritis, SLE. However, in acute pericarditis, it often is elevated. It is a good check to see how active the pericarditis is and can guide when to taper the anti-inflammatories. Another marker that we check is ultra sensitive cRP, which is also a general marker of inflammation.
elesiaturner: My symptoms are viral prodrom, low grade fever, within 24 hours severe chest pain, SOB, diaphoresis, feeling of impending doom. The acute phase lasts 3 to 4 days and responds well to steroids, recovery takes about 4 to 5 weeks, then I am fine until it happens again. My cardiologist is reluctant to call it pericarditis because I have a normal echo, ekg, etc. I have no vessel disease, but have calcification of the pericardium and higher than normal right sided pressures. Could I come to the clinic for a second opinion?
Speaker_-_Dr__Allan_Klein: We would be glad to consult with you on this condition. A little concerning would be the calcium around the heart. Pericarditis often recurs and has to be treated appropriately with anti-inflammatories, even when you are feeling well. We don't encourage constant use of steroids. If you would like to make an appointment, please call 800.223.2273, ext. 46697 and ask for an appointment with our Pericardial Center - I would be happy to see you.
Speshlk0510: I've had numerous attacks of pericarditis since Aug. 2008. I've seen 3 cardiologists, a rheumatologist, and have my primary care provider who defers to the others as he doesn't know what to do. Currently on 20 mg of prednisone daily, take pain meds as needed and still suffer acute attacks. Cardiologist has diagnosed as idiopathic and I'm wondering if there's anything else that can be done. All of the dr's I've seen including numerous ER docs don't understand why it keeps recurring, or has never gone away. They don't know which it is. Should I be searching for another dr? Living in fear of another acute attack and the possibility of it causing a fatal heart attack in extreme case is wearing on my last nerve! Any advice on what my next step should be would be helpful. Is there any other treatment I could get? Every time I go off the prednisone, the acute attack returns usually within days and I end up in ER again. I would like to be rid of it once and for all. Thank you for your time.
Speaker_-_Dr__Allan_Klein: It appears that you have steroid dependent recurrent pericarditis. You are currently trying to taper the prednisone -but every time you taper it comes back. At the Cleveland Clinic we have a Center for the Diagnosis and Treatment of Pericardial Diseases, which can appropriately treat your condition and give you recommendations how to specifically come off the prednisone and substitute the medications with anti-inflammatories that are more benign. We see these types of cases frequently at our pericardial center.
Pericarditis after Heart Surgery
karlex: in may 1908 I had a mitral valve repair., it was done minimal invasive. one week out of the hospital I got pericarditis, since then I’ve had many episodes, for a while I was doing well and now they started back again, this time its lasting more than two weeks with 75mg of indomethacin and a shot of steroid I’m still in pain. now I’m being told that the pericarditis is gone and I’m left with 'chronic pain syndrome,', I’m now put on 600mg of Motrin for a month 4xday. so my question is , my pain is exactly like I always had, with uncomfortable breathing, could I still have pericarditis or am I forever stuck with chronic pain syndrome? thank you
Speaker_-_Dr__Allan_Klein: It appears that you have recurrent pericarditis since the mitral valve repair, which needs to be treated with nonsteroidal anti-inflammatories. It would be important to check markers in the blood for inflammation - such as sed rate. At the Cleveland Clinic, we see these types of patients all the time in our Pericardial Center and we can give you more specific recommendations how to treat this condition. We would also recommend switching from indomethacin to ibuprofen or naprosyn.
brit34: I had valve surgery in February – since that time I have been in and out of the doctor and emergency room with bouts of pericarditis. Why does this keep happening to me? Is it related to the valve surgery? Will it eventually go away?
Speaker_-_Dr__Allan_Klein: What you have is pericarditis from the open heart surgery that you had. Any time that the pericardium is opened to do the open heart surgery, there could be inflammation that is ongoing. The key point is to treat the inflammation and to keep it under check. If not, the condition can worsen.
clara: If one has had bypass surgery and aortic valve replacement, does that make them a higher risk. Is there anything that they should be aware of.
Speaker_-_Dr__Allan_Klein: any open heart surgery can result in inflammation around the heart, so called pericarditis. It doesn't matter how many valve replacements or bypasses are done. Pericarditis occurs approximately 15 – 20 percent of the time after open heart surgery. Often it is self limited and disappears over time. Rarely, it becomes recurrent and has to be treated with anti-inflammatories.
Medications for Pericarditis
sammy00: When you have pericarditis – do you take steroids or anti-inflammatory medicine – I have heard conflicting things and I am concerned?
Speaker_-_Dr__Allan_Klein: When you have acute pericarditis, the main therapy should be benign medicines, such as ibuprofen or naprosyn in large doses. We often avoid steroids because even though the steroids may take away the pain, they may have the tendency to cause the pericarditis to recur. If steroids are absolutely necessary, then tapering would be key. This is because some patients become steroid dependent with pericarditis.
Another key medicine would be an older anti-inflammatory called colchicine which had been used in the past to treat our grandfathers with gout. The combination of the ibuprofen as a first line and the colchicine as the second line in combination would be the general approach.
flowergrl00: I was diagnosed with pericarditis a week ago and I think I am fine – I do not have intense pain any more. Is there anything I should do at this point to prevent it from happening again?
Speaker_-_Dr__Allan_Klein: Pericarditis often does recur. You probably should be on anti-inflammatories such as ibuprofen three times a day to prevent recurrence for several months. Make sure that you have medicine to protect your stomach, such as omeprazole. Often, it may be self limited but on the other hand can recur and become a nuisance.
frankem: Is there danger in taking Colchicine for an extended period of time - - as a preventive measure vs. treating acute symptoms?
Speaker_-_Dr__Allan_Klein: Colchicine is usually a benign medicine that should be given as a second line therapy after nonsteroidal medicines like ibuprofen. Over time, the colchicine can gradually be withdrawn. The main side effects of colchicine would be GI symptoms such as diarrhea. Rarely it could affect the bone marrow and lower sperm counts. Thus, even though it is benign, monitoring is necessary. In addition, liver function and renal function should be checked.
In acute pericarditis often we start with ibuprofen around the clock. If there is still recurrent pain after several months, then we often add colchicine. After several months of improvement, we can start to taper the ibuprofen. The last to go would be the colchicine.
Pericarditis Signs and Symptoms
MelissaB: If you have chest pain that does not get worse with activity – but does get worse when sitting forward or breathing in deep – is that pericarditis?
Speaker_-_Dr__Allan_Klein: Yes - it would be important to check markers for inflammation as well as to get an echo to see if there is any fluid around the heart.
Dennis: Is atrial fibrillation associated with pericarditis. I have pericarditis and I have been treated with Motrin and Colchicine. Now I have atrial fibrillation which is new – is it related?
Speaker_-_Dr__Allan_Klein: Atrial fibrillation can be associated with pericarditis. On the other hand, there are other conditions that cause atrial fibrillation including hypertension, coronary disease, and the aging process. Yes - definitely pericarditis can also be associated with the atrial fibrillation.
jamesj: I have pericarditis – when I lie down I feel my chest rubbing and it is uncomfortable. So – I can’t sleep at night – any ideas doc?
Speaker_-_Dr__Allan_Klein: What you have is a common symptom of pericarditis. It would be important to be on anti-inflammatories to treat this condition. Often breathing makes it worse and often it radiates to the left shoulder. If you have this, you should see your doctor to get started on medicine like ibuprofen around the clock.
Jadegrl: My mom has heart failure and has had a partial pericardectomy 3 months ago. She also has an irregular heart beat. Will her heart failure improve?
Speaker_-_Dr__Allan_Klein: Hopefully, the pericardectomy should improve the heart failure. If it does not improve it, then evaluation of the heart function and how the muscle is working should be done. Alternatively, the pericardectomy may have been incomplete. Arrhythmias often result from pericardial disease and should get better with the treatment of the pericardial disease.
JimB_54: My doctor told me I have fluid around my heart – is that pericarditis?
Speaker_-_Dr__Allan_Klein: Fluid around the heart can be associated with pericarditis. We often grade the fluid like the three bears - small, medium and large. If the fluid is large, we often will have to remove it. If it is small or medium, we just watch it.
krt65: My husband has been having chest pain. He had a cath and 2 stents placed last month. His chest pain did not go away – the doctor thinks it may be inflammation of the heart – what is that from? Is that pericarditis and how should it be treated?
Speaker_-_Dr__Allan_Klein: Chest pain can be caused by many things including pericardial disease. The typical pain of pericardial disease is usually sharp pain in the chest which increases with breathing, often radiating to the left shoulder. On the other hand, your husband does have coronary disease, which also causes pain. The key differences are often detected with measurement of anti-inflammatory markers, echocardiograms, and MRI tests. It would be important for his doctor to try to distinguish these two conditions.
The first step would be to check the markers for inflammation. The key point is whether the chest pain started since the stents or was there before the stents.
Procedures for Pericardial Disease
lkim: My mom has fluid around her heart and they want to put a window in the pericardium – is that what you do for that? What is the procedure – does she have surgery?
Speaker_-_Dr__Allan_Klein: Pericardial window can be done for fluid around the heart often when the fluid is difficult to get there by a needle. However it is surgery.
natie2: What is the difference between pericardiocentesis and pericardial window?
Speaker_-_Dr__Allan_Klein: Pericardiocentesis is often done by a cardiologist where using echocardiography, a needle is directed into the pericardium to remove the fluid. A pericardial window is performed by a cardiac surgeon, where a small surgical incision is made to drain the fluid. Often, a biopsy can be done with the window. Often the windows are done for more recurrent problems, while pericardiocentesis is done more urgently.
clara: What are the symptoms of constrictive pericarditis?
Speaker_-_Dr__Allan_Klein: The main symptoms of constrictive pericarditis are the following: shortness of breath; belly swelling; ankle swelling; a large liver; fluid in the lungs; trouble lying flat; having to sleep in the chair; a lot of diuretic use; Calcium around the heart by chest x-ray or CT scan. At the Cleveland Clinic, we see patients with constrictive pericarditis frequently and specialize in the diagnosis and treatment of this disease with a team approach involving cardiologists, radiologists, and cardiac surgeons.
tim_b: I was told I have calcification of the pericardium – what is that? How is it treated?
Speaker_-_Dr__Allan_Klein: Calcific pericarditis can be associated with pericarditis several years earlier with recurrent inflammation. Calcium means that it has been there a long time. The key point is to know whether the calcium is compressing the heart and thus be causing constrictive pericarditis, which is a surgical condition.
Not all calcium around the heart is constricting. At the Cleveland Clinic Pericardial Disease Center, we see these types of patients all the time. You definitely should have a complete work-up, including imaging of the heart to assess whether you have constrictive pericarditis.
Myocarditis and Pericarditis
michaelv: I had myocarditis 5 years ago – this year I was diagnosed with pericarditis – is that strange? Are they related?
Speaker_-_Dr__Allan_Klein: They are related. Since the viral condition can affect either the outer layer - the pericardium - as well as the muscle layer - the myocardium. Depending on the severity of the attack, you could have either myo-pericarditis or peri-myocarditis. If the muscle is more involved than the pericardial lining, this is a more significant condition.
Rheumatoid Arthritis and Pericarditis
caroline_d: I have had rheumatoid arthritis since I was in my 20’s. Recently I was diagnosed with pericarditis. They are both related to inflammation – is it common for people with RA? How is it treated for people with RA?
Speaker_-_Dr__Allan_Klein: Pericarditis is very common in patients with rheumatoid arthritis (RA). Usually the treatment of the RA improves the treatment of the pericarditis. If the RA is under check with immunosuppressive therapy, then the pericarditis should get better. As part of the Pericardial Center, we have a team of rheumatologists who would be glad to evaluate you.
jet: My dad had heart surgery last week – now he has a pericardial effusion. What is that and is it serious?
Speaker_-_Dr__Allan_Klein: Pericardial effusion often occurs after open heart surgery. Most of the time it resolves by itself. It is not dangerous unless it is large.
Left Ventricular Hypertrophy (LVH)
curious28627_2: In Oct 2004 I had an Echocardiogram. I have had hypertension since 1996 which is treated now with generic lotrel. Results of echocardiogram show Mild Concentric LVH, no wall motion abnormalities Estimated LV ejection fraction 55-60%.
Speaker_-_Dr__Allan_Klein: Concentric Left Ventricular Hypertrophy (LVH) is often related to the hypertension that you have. That should be treated with anti-hypertensives which you are taking. The key thing is to follow the blood pressure and make sure it is appropriately being treated.
sarah_76: My aunt has a pericardial cyst – what is that and how is it treated?
Speaker_-_Dr__Allan_Klein: Pericardial cyst is a benign condition - it is a collection of fluid in the form of a cyst, usually adjacent to the right heart border. We often follow this condition with out any surgery. If the cyst gets too large, we can consider removing it. Once again, at the Pericardial Center, we see these conditions frequently and would be glad to provide a complete evaluation.
Mel15: My uncle had asbestos and has cancer of the pericardium – just diagnosed a couple weeks ago. Can they remove the pericardium and treat it that way?
Speaker_-_Dr__Allan_Klein: Tumors of the pericardium are serious and have to be evaluated by a cardiac or thoracic surgeon. It would be hard to make a recommendation without evaluating your uncle. At the Cleveland Clinic, we have a team of surgeons that can evaluate your uncle if you like.
tiffany: In 2003 I had pericarditis with 1/2 liter of blood water removed no window was cut. Then I had thyroid storm which caused me to go into third degree block which point a two wire pacemaker was installed, since then I am in 100% pacing mode. Recently I have been diagnosed with a rare tumor in my left atrium, wrapping around the inner wall of my heart. I have under gone the following test echo, tee, cat scan, pet scan, and biopsy. I have been told I need further testing or open heart surgery to determine what is going on. I would like to know if you think there could be a correlation between the original pericarditis and subsequently my tumor? Help...
Speaker_-_Dr__Allan_Klein: I think that the current tumor in your atrium is probably unrelated to the pericarditis, pacemaker and thyroid connection.
tiffany: Do you work with the doctors in Florida? If not can you recommend someone who knows about pericarditis and pericardial diseases? Thank you.
Speaker_-_Dr__Allan_Klein: We have a Cleveland Clinic Florida in Weston. They have many qualified cardiologists to address the condition. Our Center for Pericardial Diseases is only located in Cleveland.
tiffany: Thank you very much for answering my questions. I would like for you to evaluate me? When can I come to see you? In the mean time is there anything I can do or take to feel better?
Speaker_-_Dr__Allan_Klein: We would happy to see you. Before we make any specific recommendations, it would be important to assess you in person.
tiffany: Dr Klein: Do you think I have pericardial disease since, I've had pericarditis, thyroiditis, sinusitis, third degree block, and cardiac tumor? I am always short on breath. My pet cat scan showed my lungs are clear so, I am wondering if this is all related to the pericarditis?
Speaker_-_Dr__Allan_Klein: It is possible to have auto-immune processes that affect the body such as thyroiditis. Usually there is evidence such as conditions such as rheumatoid arthritis or lupus involved. The cardiac tumor is usually a separate issue. Depending on how large the tumor is, what it is whether it is compressing would be important to know whether the tumor is a cause of your shortness of breath. You may have more than one condition - pericardial disease and cardiac tumor. We would be glad to evaluate you at the Pericardial Center. We have a lot of experience with cardiac tumors as well as pericardial disease. If the tumor has to be removed, we would also refer to cardiac surgery.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Klein is now over. Thank you again Dr. Klein for taking the time to answer our questions about pericardial diseases and treatment options today.
Speaker_-_Dr__Allan_Klein: Thank you for having me.
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