Pericardial Conditions (Drs Klein&Johnston 7 12 11)
Tuesday, July 12, 2011 - Noon
Pericarditis develops suddenly and may last up to several months. Sometimes excess fluid develops in the space between the pericardial layers and causes a pericardial effusion, a potentially life threatening condition. Dr. Klein, Director of the Center for Diagnosis and Treatment of Pericardial Diseases and Director of Cardiovascular Imaging Research and cardiac surgeon, Dr. Johnston answers your questions about pericarditis as well as other pericardial diseases.
Cleveland_Clinic_Host: Welcome to our "Pericardial Conditions" online health chat with Allan Klein, MD and Douglas Johnston, MD. They will be answering a variety of questions on the topic. We are very excited to have them here today! Thank you for joining us, let's begin with the questions.
Diagnosis of Pericarditis
Islandheart: I am being treated for Pericarditis since my bypass surgery in January. However, they typical test for Pericarditis are normal. It does not show up in my EKG, Echo, chest x-ray, Sed. rate is normal, nor was a rub heard. My diagnosis was based on the fact that I was running a low grade fever daily, had little needle-like stabbing pains around the heart, felt very sick and very tired. Do you think this diagnosis is correct? I was treated with Motrin 800mgs daily with no improvement. Diclofenac was added twice a day with only slight improvement and finally colchicine once day with a big improvement--not feeling my old self yet, but much better. What do you think of the use of Diclofenac?
Dr__Allan_Klein: In making the diagnosis of pericarditis - there are 4 criteria:
- physical chest pain
- friction rub
- EKG changes
- new or worsening pericardial effusion
You only had a low grade fever - you did not respond to Motrin or Diclofenac therefore your diagnosis is questionable. Your sed. rate was also normal and no rub was heard and I assume no pericardial effusion on echo. It doesn't rule it out but it is questionable.
Harriet: my question is, if one has an echocardiogram, would it show signs of pericarditis or is there other imaging required to diagnose? Thank you
Dr__Douglas_Johnston: Echo can help in the diagnosis but we are on the forefront of utilizing MRI to assess the degree of inflammation and assist with diagnosis.
Islandheart: Will an MRI show inflammation if you are not currently having a flare up? I find that by the time I get to the doctor or radiologist, my symptoms are reduced and nothing shows up.
Dr__Allan_Klein: MRI should show inflammation even if you are not having a flair up - but it usually goes hand in hand. There may be a lag when the markers are normalized. Ongoing research is addressing MRI information.
lynn1112: How does a right heart cath aid in the Dx of pericarditis?
Dr__Douglas_Johnston: It aids in the diagnosis of pericardial constriction by measuring the pressures on the right side of the heart and can differentiate constriction from other conditions that cause heart failure.
Symptoms of Pericarditis
songcanary: I was diagnosed with moderate pericardial effusion during an autonomic workup. Three subsequent echos have been unchanged and I have no symptoms. What symptoms would indicate a worsening of this condition? And how often should I have repeat echos?
Dr__Allan_Klein: It is not uncommon to find an asymptomatic mod pericardial effusion. If it progresses the patient may have shortness of breath. I would suggest echos every 6 months to one year to assess change.
kth_1: Could shoulder pain and discomfort & cough when lying down be chronic pericarditis? (I've had several episode of acute pericarditis).
Dr__Allan_Klein: It is usually left shoulder pain and pleuritic chest pain when breathing in when lying down - could be symptoms. Chronic pericarditis means it occurs greater than 3 months after the initial episode - it could be that your symptoms are chronic pericarditis.
hssutton: Do the sound of crackles indicate pericarditis?
Dr__Douglas_Johnston: no - in general crackles indicates fluid in the lungs or pulmonary edema.
Causes of Pericarditis and Pericarditis Associated with Other Conditions
jep13: In 1971 while serving in the United States Navy, I was hospitalized with Viral Pericarditis. Two years later I had to take a pre-employment physical which included an EKG. The examining doctor upon looking at the results of the EKG asked me when I had a heart attack and I told him that I had not had one that I was aware of. I then told him that I had Viral Pericarditis while serving in the Navy and he said that explains the abnormal EKG. Today, 40 years later I have Ischemic Heart Disease, have had three Heart Attacks, and have had to 5 stints installed in various coronary arteries. Can my past and present CAD be related to my earlier Viral Pericarditis?
Dr__Allan_Klein: I don't think so. I think the viral pericarditis is unrelated to the ischemic heart disease.
Dr__Douglas_Johnston: I agree it sounds like two separate conditions.
harbour18: Hi: Is pericarditis related at all to lupus or other auto immune/inflammatory conditions? Also, would it show up on an echocardiogram? Thank you.
Dr__Allan_Klein: Lupus can cause pericarditis. It is not uncommon in system autoimmune inflammatory conditions. It would show up in an echo. Often the pericardial effusion is secondary to the lupus.
lynn1112: How serious a threat can pericarditis be to one who has moderately severe DCM,EF of 15-20%, and who goes into CHF 2-3x's a year requiring hospitalization?
Dr__Allan_Klein: The baseline condition of systolic impairment and heart failure. pericarditis can be troublesome esp if you develop an effusion. The NSAID would be contraindicated due to impact of kidney function and fluid retention. This type of patient should be seen in a center of excellence for pericardial disease.
soulmyster: What causes pericarditis?
Dr__Allan_Klein: Classification of pericarditis - could have infectious or non-infectious. • Infectious is most often viral/idiopathic • Non-infectious most common is auto-immune pericarditis such as lupus, pericardiotomy syndrome and neoplastic. Most pericarditis would be viral or idiopathic.
traceywa: I was diagnosed with Dressler's syndrome after mitral valve repair in 2007. Prior to being placed on colchicine I had 13 episodes of pericarditis and pleurisy. I have been taking .6mg of colchicine since October 2007 which has reduced the episodes to about 2-3 annually. What could be potentially the cause even though I am taking medication? Since being diagnosed with Dresslers my average heart rate is 90 even though I have been placed on toprol. Could this be caused by Dresslers?
Dr__Allan_Klein: Dressler's syndrome can be the cause of your pericarditis. You get damage to the lining and it sets up an auto immune process so even 4 years later you can have recurrent pericarditis.
You should probably be on an NSAID as well as colchicine. You should check markers of inflammation to see how active the pericarditis is. Also an MRI to see the extent and to see if you have constrictive pericarditis.
Dr__Douglas_Johnston: If the pericarditis is refractory and if the patient has complications due to chronic steroid use - we do surgery in this case and the surgery can be very effective allowing the patients to get off the medications.
Links: What is the incidence of pericarditis post chest radiation for carcinoma of the lung?
Dr__Allan_Klein: I don't have the exact incidence - but radiation for lung cancer can cause pericarditis and pericardial effusion and should be followed with echocardiogram.
Recurrent and Chronic Pericarditis
SheliaM48: ( 1) Is it possible to have recurrent pericarditis? and (2) Can a calcification on the pericardium increase in size or worsen? and (3) Are there any clinical trials available? I was diagnosed with a pericardial calcification in 2006 (constriction not ruled out) and I suffer periodic shortness of breath.
Dr__Allan_Klein: 1. Yes - it is possible to have recurrent pericarditis after acute pericarditis. It occurs 20% of cases. 2.Calcification can grow. If you have calcification and shortness of breath, then constriction should be ruled out. 3. The only trials out there are with regard to colchicine and acute and recurrent pericarditis and also on pericardiotomy syndrome. Search for article by Farand and Côté; CORE and COPPS trials are in the literature at PubMed (http://www.ncbi.nlm.nih.gov/pubmed) or you can try www.clinicaltrials.gov.
richg: I have had five episodes (4-7 days) of pericarditis beginning about a month of my mitral valve repair surgery (early March). I am taking .6 mg colchicine twice a day and have generally been taking 600 mg of Advil three times a day except my cardiologist has me tapering down the Advil. He wants me to double up on the colchicine, instead, when I am having an episode. Do you think this is the right approach? Also, if you have recurrent If you have recurrent pericarditis, how do you know when you are in the clear and no longer need to take medicine?
Dr__Allan_Klein: After MV repair, pericarditis can occur shortly after - about a week after surgery. The Advil 3 times a day and colchicine 2 times a day are appropriate Advil dosing should be based on symptoms and markers of pericarditis. You should have your sed. rate and your US-CRP tested. If they normalize from previous elevation - it is appropriate to taper the Advil. If elevated, they can be continued.
You can get into the stage of recurrent pericarditis - usually this means the acute episode has passed and now you are having recurrent episodes. Three months is usually the cut off from acute to recurrent.
Dr__Douglas_Johnston: The majority of cases that are early like this usually resolve with medication. Checking the labs is important with regard to getting off treatment.
kth: After post ablation, cardiac tamponade and acute pericarditis I am concerned that I may develop chronic pericarditis. I am on a tapering dose of prednisone. How is chronic pericarditis diagnosed and what is the best initial treatment?
Dr__Allan_Klein: Pericarditis after pacemaker and ablation procedures is not infrequent. If there is blood in the pericardium, this is a strong irritant. You are being appropriately treated with prednisone - but you should also be on colchicine and NSAIDs as well to allow the tapering of the prednisone.
Chronic pericarditis means that it occurs after 3 months. It is diagnosed with clinic evidence, inflammatory markers and echo.
vottagt: I have had pericarditis 4 times since Feb. My Dr. has talked to me about doing a window in the lining to drain the fluid, he has also spoke to me about a more invasive treatment, pericardectomy? I am treated with pain meds and steroids each time I have an issue, I have lupus, hep c ( now have cirrhosis due to the hepc, from a bad transfusion) so I am limited to what meds I can get, I am on effient,(plavix did not work, I had stenosis after my heart attack and stent) digoxin, enalapril, coreg,simvistatin, I also have to take pantoprazole to protect my stomach in case of bleeding, I am on colcrys and bupropion too. I am a 57 year old female. My question, is there another treatment that may be more beneficial for me?
Dr__Douglas_Johnston: Sounds like a complicated case and we would want to review all your studies. You would benefit from all the attention of the experts at the Pericardial Center.
athram: Is recurrent pericarditis a lifelong condition?
Dr__Allan_Klein: It is not lifelong and most of the time it will gradually clear itself over years. Constrictive pericarditis is unusual to have after recurrent and recurrent will usually burn itself out after several years.
kmyers: How many cases of constrictive pericarditis do you treat at Cleveland Clinic every year?
Dr__Douglas_Johnston: Including clinic visits, that would be over 100. Surgeries are about 35 - 40 per year.
kmyers: Is Constrictive Pericarditis especially difficult to diagnose?
Dr__Douglas_Johnston: No - not with the appropriate combination of echo, sometimes MRI and sometimes a right heart catheterization.
lacroixg: cyclist asks: What is the difference between recurrent and constrictive pericarditis? How do you diagnose the difference? Are the treatments and recovery scenarios the same? Does constrictive peri reduce stroke blood volume and lead to elevated heart rate, shortness of breath, and inability to do sustained cardio exercise?
Dr__Allan_Klein: Recurrent pericarditis is basically chronic pericarditis that recurs It can be incessant meaning that you cannot get off the prednisone without having symptoms or can be intermittent.
Constrictive pericarditis is different from recurrent. There are elements of heart failure - esp right sided heart failure; due to thickened or inflamed pericardium and often treated with surgery.
Exercise and Pericarditis
lacroixg: I had three diagnosed episodes of pericarditis at 2-3 week intervals this winter. It took me a month of bed rest to recover after the last episode. I am still unable to do any exercise without my pulse rate shooting up (>180 bpm) and taking hours to recover (100-120 bpm). I am 57 and have been a cyclist for more than 30 yr. I used to be able to cycle up mountains for 3-4 h and my HR would not exceed 160-165 bpm and it would recover to 120-140 bpm in minutes if I relaxed my effort. My cardiologist has done a CT with contrasting dye and concluded that he did not need to see me again and to proceed with exercise. Could there be some related injury or scarring or other that is affecting my heart rate ( and breathing effort) during activity. Should I be seeking further medical advice and what tests would you recommend? Thanks.
Dr__Allan_Klein: with regard to exercise and pericarditis - if you have active or acute pericarditis, exercise is not the best thing. If it recurs, you should not be cycling up mountains. While you are pain free, cycling or increase in activity should be gradual. CT is not a bad test for looking at the lining but probably a full evaluation at a pericardial center would be the best medical advice.
Medications for Pericarditis
tiredofpericarditis: I was diagnosed with pericarditis 15 months ago and continue to have no more than a month at a time without symptoms. I have been on Advil, Indocine, and now Naproxen. Each seemed to work well at first, then lose their effectiveness, causing my symptoms to return. The primary symptoms are dull aching chest pain, pleural type chest pains, and shortness of breath. All symptoms are worse lying down. EKG's and 2 cardiac echos are normal. Sed. rate is normal and I am ANA negative. Are there certain NSAIDS you prefer over others? Is it normal for NSAIDS to lose their effectiveness? Is there something other than NSAIDS to try?
Dr__Allan_Klein: The patient Should be on a combination of colchicine 0.6 - 2 times a day and Ibuprofen 800 mg 3 times a day and PPI (such as prilosec 40 mg 1x per day) for the stomach to protect from gastric ulcers.
Rebecca: The cause of my pericarditis is unknown. I've been taking indomethacin for eight weeks, along with colchicine for six weeks and a Prilosec substitute for several days. What is the usual course of this disease? What makes it go away? i.e. if the medications haven't worked so far, why should they eventually be effective? How dangerous is a garden-variety case like mine?
Dr__Allan_Klein: The most common cause of pericarditis is idiopathic - no known cause.
- Your medical therapy is appropriate.
- It may take several months to get under control. It can recur in 20 % of cases.
- We usually follow markers of inflammation such as sed. rate and US-CRP.
- High risk features of pericarditis such as a fever, a gradual onset or a subacute course, a large pericardial effusion and cardiac tampanade (fluid around the heart) may require hospitalization and more aggressive therapy.
At the Cleveland Clinic the Pericardial Center physicians often does imaging of the pericardium such as echo and MRI to visualize how inflamed the pericardium is and helps to guide therapy. We see about 800 - 1000 patients each year with pericardial diseases
tc67: Doctors, I am an otherwise healthy 44 year old woman who had my aortic valve replaced with a bovine valve 26 months ago, due to a congenital defect (conjoined leaflets). The minimally-invasive surgery and subsequent recuperation went well, other than leaving me with chronic pericarditis that I can't seem to shake. I take Colcrys, Naproxen and Prednisone, which help with the symptoms, but never eliminate them. My cardiologist mentioned Dressler's Syndrome as a possibility, but he has never seen the condition last this long. In your experience, have you encountered this type of scenario, and can I still expect it to resolve over time? Are there diagnostic/clinical treatment programs available at Cleveland Clinic that would have a high likelihood of success in ridding me of this painful and nagging condition? Thank you for your time today.
Dr__Allan_Klein: At the pericardial center at Cleveland Clinic - your condition is not that abnormal - after surgery on 3 - 4 medicines. The goal of therapy is to get you off the prednisone - taper the prednisone while taking the NSAID and colchicine. We do use imaging to determine the amount of inflammation to help guide therapy.
Dr__Douglas_Johnston: In some cases when patients are refractory to therapy in the long term, we do offer surgery to remove the pericardium. This has been very successful.
Zippo: How and when does one taper off on the medication? When all symptoms are gone ? Some time after that? And how? Could you give a schedule involving indomethacin 50 mg. and colchicine .6 mg? Thank you.
Dr__Allan_Klein: We need the anti-inflammatory markers to know if they are elevated and clinical symptoms. It is a gradual taper. We often use ibuprofen rather than indomethacin because it has a bigger dose range. : Indomethacin is a twice a day - so you would gradually decrease to 1/2 a dose and wait a month to see how you are doing. Colchicine would be the last drug to come off.
I want to emphasize that we use the markers to help guide us as to when you should come off your meds.
Liz930: I had flu symptoms in Feb and then acute pericarditis with effusion. Rx with naproxyn. Recurred 3 weeks later. Rx with Prednisone x 4 days. Recurred with moderate pericardial effusion and bilateral pleural effusion. Rx with Prednisone. Have been attempting to wean slowly off Prednisone but when I wean down to less than 20 mg per day symptoms return. No other significant history. Is this common? Is there another approach? Should we be looking at an underlying disorder as the cause?
Dr__Allan_Klein: It is not uncommon to have a more aggressive course of your pericarditis.
While on the prednisone taper, you should also be on the colchicine and NSAID to assist you to taper. In terms of the prednisone taper, it has to be a very slow process. If you are on 20 mg, we would taper 2.5 mg every 2 weeks to a month. Unfortunately it may take several months to a year to treat this. If you get to 10 mg of prednisone, it would be 1 mg decrease every month - a very slow taper.
traceywa: Colchicine has recently, I believe because of regulations, become more expensive and my doctor is prescribing in smaller doses. Do I need to be worried that it will not be available? Is there an alternative?
Dr__Allan_Klein: Colchicine is now in a new formulation called colcrys. It is a more purified colchicine . For the cost - there are vouchers you can get from the company. You can go online to check with the company or check with your local pharmacy for the colcrys. The doctor should not be giving smaller doses.
glennp01: I have been diagnosed with recurrent pericarditis (4 times since January 2011). Last time hospitalized was May 5, 2011. I'm 43 and generally good health. Been steady on Prednisone since April. If I drop below 20mg of Prednisone, pericarditis reoccurs. My question --> My family doctors thinks side effects of Prednisone bad for long term. Cardiologist wants me on Pred for next 10 months with slow wean. What would be your opinion? (I know, very little information from me). Thanks.
Dr__Allan_Klein: Go to a center of excellence for pericardial disease to suggest how to taper prednisone. However you should be on colchicine and NSAID to taper the prednisone. For specifics you should consult a center of excellence. We see these patient cases very often and have been very successful in getting the prednisone to the very lowest possible dose.
kth_1: After tapering off prednisone can pericarditis worsen?
Dr__Allan_Klein: Not infrequently when patients come off prednisone, patients can have a recurrent incidence of pericarditis - that is why it is important to be on the other two meds when coming off the prednisone.
kth_2: If I am taking warfarin could I still take NSID and colchicine in addition to prednisone for pericarditis? I have GERD.
Dr__Allan_Klein: That is a complicated situation. With warfarin NSAID is not the best idea. In addition with GERD and coumadin, steroids are not the best idea either. We often give colchicine. You should be seen at an experienced Center of excellence.
Surgical Treatment for Pericarditis
kmyers: You do 35-40 complete pericardectomies a year? Is that number on the rise? When my husband had his surgery in 2004, it took 2 full years, and many specialists to finally diagnose it.
Dr__Douglas_Johnston: That number is slowly increasing. It is unfortunate that patients do not get diagnosed early or treated early for their pericardial restriction. We are hopeful that the Pericardial Center will increase awareness and help patients get treated earlier.
Links: What are the risks of pericardiocentesis?
Dr__Douglas_Johnston: Injury to the heart; bleeding; cardiac tampanade and recurrent effusion.
Dr__Allan_Klein: At the Cleveland Clinic pericardiocentesis is echo guided to minimize complications. If this is very difficult due to location, we can offer a pericardial window.
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