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Pericarditis (Drs Klein&Johnston 4 30 12)

Monday, April 30, 2012 - 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.

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Causes of Pericarditis

twest: My 23 y.o. son was in ICU in Jan for pericarditis and pleural effusion. One marker was positive, and they diagnosed him w/lupus, but further tests were negative. We're still not sure as to cause. He is still struggling after 4 months to decrease prednisone. Is this common for a young male? Advice on prognosis or further testing?

Dr__Klein: It sounds like your son had a pretty active case of pericarditis - most likely viral if lupus and other rheumatologic conditions have been ruled out. It is important to stage how active the inflammation is as mentioned before with inflammatory markers and imaging tests such as MRI and echo.

He may have to be on triple therapy with NSAID, colchicine as well as prednisone. It would be important while on prednisone not to wean too quickly but the other agents may allow him to gradually taper the prednisone. A case like your son's should probably be evaluated at a major medical center.

twest: He is being treated at George Washington University. We are thinking of making a trip to Cleveland.

Dr__Klein: George Washington University is a fine institution but there are very few specialized clinics in the country for Pericarditis.

askaway: Are there medical conditions or chronic diseases that predispose patients to pericarditis? If so, what are they? Thank you

Dr__Klein: There is a whole list of causes of pericarditis - in particular the rheumatic conditions such as lupus or rheumatoid arthritis - there are medical conditions such as hypothyroid that can cause pericardial effusion. The most common causes are viral or idiopathic. Another cause is iatrogenic - post procedure - such as ablation, pacemakers, and trauma to the chest.

cmk123: I was diagnosed with pericarditis two years ago days after getting the H1N1 vaccine. I have had recurring episodes over the past couple of years, but more frequently the past two months. I am seeing my general practitioner at this point, not a cardiologist. Should I go back to the cardiologist? Which inflammatory markers are the ones that my doctor should be checking for?

Dr__Klein: I would suggest that you should check the CRP, sed rate, also check troponins. It is pretty unusual complication after getting the H1N1 vaccine - you should follow up with a cardiologist who has experience treating pericarditis.

nschrader: I had a pacemaker 2 years ago and my lung was punctured by the wires. After that I developed pericarditis. Could this be the result of the lung puncture?

Dr_Johnston: It is very possible that this is a result of the puncture - however this would have had to puncture the heart to get to the pericardium. Anything that causes bleeding into the pericardium can be a cause of future pericarditis.

Symptoms of Pericarditis

JennyP73: How long after a bout of pericarditis is it normal to still feel high levels of fatigue and chest discomfort?

Dr__Klein: Pericarditis takes several weeks to improve. so - it is not uncommon to have those symptoms such as residual chest discomfort. It may imply that the pericarditis has not been fully treated so you should probably follow up with your inflammatory markers such as CRP and sed rate to check to see if there is still inflammation that is ongoing.

Diagnostic Testing

Jebosley: Can an echo alone diagnose pericarditis?

Dr__Klein: To diagnose acute pericarditis - you need 2 out of 4 criteria - the main criteria would include classic pleuritic chest pain, a doctor diagnosing a pericardial rub when listening to the patient, classic EKG changes and also pericardial effusion by echo.

In addition, we use the inflammatory markers crp and sed rate and now with advance imaging we use inflammation as seen by MRI which shows the whole pericardium and inflammation.

Jebosley: Is it safe to get a MRI to evaluate the pericarditis and pericardial effusion if you have stainless steel wire in your chest wall from previous surgeries?

Dr_Johnston: Yes.

Recurrent Pericarditis

Coal: I was diagnosed with chronic recurrent pericarditis of unknown etiology 4 years ago. Since then I have had numerous recurrences and never was able to stop taking prednisone. The doses I am taking vary between 60.00 to 5 mg depending on my condition. What can be the cause of these recurrences and is there a way to permanently discontinue prednisone?

Dr__Klein: We see this type of patient very often in our Pericardial Center. It is a difficult problem to taper the prednisone. Our key policy is a very slow taper as long as you are on steroid sparing medications along with that such as NSAIDs and colchicine - we call this triple therapy. The tapering is as slow as 2.5 mg of prednisone every 2 - 4 weeks.

Coal: from what amount of prednisone?

Dr__Klein: Usually that is from if you were on a high dose such as 40 mg, but as you get down as low as 10 mg, we may taper as slow as 1 mg a month.

fian: I have had 3 flare-ups and 3 minor episodes of Pericarditis since December and have spent February and April on Ibuprofen and Colchicine. I am still getting tightness in my chest occasionally and feel tired and lethargic often. Should I be continuing with this medication indefinitely and would it be ok to get some exercise? I have been inactive for a month now and am normally very involved in training.

Dr__Klein: It is not unusual to have residual tightness after pericarditis. It would be important to check inflammatory markers to see if the pericarditis is being adequately treated. If there is active pericarditis it would not be the best thing to vigorously exercise although between episodes, it is ok to increase the activity level.

nschrader: I get pericarditis about 3 or 4 times a year. There is no fluid, just inflammation and some pain. I take aleve for the pain. It usually lasts about 2 to 4 weeks.

Dr__Klein: The management of your particular case suggests you should probably be on a small dose of NSAID such as ibuprofen or naprosyn during the year to prevent further attacks.

rzagotta_1: I have been dealing with idiopathic recurrent pericarditis on and off for 10 years. does this condition ultimately resolve? if so, in what timeframe?

Dr__Klein: Eventually the condition will get better and burn itself out. It is hard to know when it will stop but hopefully soon.

Chronic Pericarditis

Venus: Hello, I have been suffering from chronic idiopathic non-effusive pericarditis for about a year and a half. I have been to the ER a few times and I've had follow up visits/tests with cardiologists and a rheumatologist. They have not been able to determine a cause. To date there has been no fluid build-up in the pericardium but the pain and fatigue has ranged from moderate to severe. The episodes last a few days, a few weeks or up to a few months. The plan of action from the doctors is to take over-the-counter non-steroidal anti-inflammatory medication until it becomes too severe. When it gets worse I take Indomethacin for the inflammation and Norco for the pain. If it gets too unbearable I go to the hospital to take care of the pain and for tests to make sure that the condition has not become constrictive. I have tried Colcrys and it did not help, also my stomach did not tolerate it. My question is, does this sound like the best plan of action or is there something else that I could/should be trying?

Dr__Klein: We see these types of patients very commonly in our Pericardial Center. A key thing is to stage how bad the inflammation is in the lining of the heart by imaging tests including echo and MRI and inflammatory markers.

A case like this seems to be related to what we call the "yo-yo effect" meaning the medicine has been tapered off too quickly and then it has to be restarted like a yo-yo. You as the patient may need very close attention otherwise you may end up on narcotics and become narcotic dependent.

gilbertazcp: Can the time from mild to severe take many years? Mike

Dr__Klein: Yes.

Constrictive Pericarditis

JennyP73: Is it possible for someone with a history of chronic pericarditis (and a related pericardial effusion and a pleural effusion) to experience early stages of constrictive pericarditis without displaying symptoms such as shortness of breath or swollen abdomen? If so, what other indicators are there?

Dr__Klein: It is possible to have early stages of constriction without shortness of breath or swollen belly. This is often picked up by an imaging test such as echo or MRI. As it progresses, however, the symptoms such as swollen abdomen may develop. There are different forms of constrictive pericarditis - mild, moderate and severe. The early stages would be considered mild.

gilbertazcp: I had a heart stress test and echo back in 2004 and an echo in 2008 because I felt a lack of oxygen while playing basketball. The tests revealed no problems. In November 2009 I had bronchitis which was followed by swelling in the extremities and minor ascites. My question is could the constriction have been building up over time and the bronchitis was the last straw, or can the bronchitis by itself be the cause of the constriction?

Dr__Klein: The lining of the lungs and the lining of the heart are adjacent to each other so it is possible that whatever caused the bronchitis could be causing the constriction. So - they could be related, most likely viral.

Medications for Pericarditis

mpeek1927: What is the window of opportunity for successful treatment of pericarditis? At what point/period of time is beginning of treatment vital to cure?

Dr__Klein: That is a very important point to treat as early as possible to try to avoid complications such as pericardial effusion or constrictive pericarditis. With our therapies we think we can change the natural history of people who have pericarditis. The best window is early.

Coal: do you have experience in treating chronic recurrent pericarditis of unknown etiology with immunosuppressive drugs for "prednisone hooked” patients. coal

Dr__Klein: For this particular type patient it is very important to consult a rheumatologist who may suggest immunosuppressant medications as well as disease modifying agents such as methotrexate, imuran and anti-TNF blockers. Occasionally these more powerful drugs can help in allowing you to come off your prednisone. We have some experience with these patients, although we would consult rheumatology as well.

beave: I was diagnosed with pericarditis seven years ago. No recurrence for two years, then a minor episode every five to six months - mild chest pain, weakness, nausea, light-headedness. Then the episodes began occurring every two to three months, but milder with no chest pain. My cardiologist is concerned that every occurrence will cause scarring, so I am on indomethacin (25 mg) daily for six months. I am four months into the treatment with only one minor episode (no chest pain). Will this treatment knock it out, or will I need to continue taking the indomethacine continually?

Dr__Klein: I would suggest switching from indomethacin to something more benign such as ibuprofen or naprosyn. It is true that with more recurring episodes there can be some scarring of the heart but be sure if there is another attack to check the inflammatory markers to make sure the pain or symptoms are actually from pericarditis.

faride_1: I am a pericarditis patient. Can you discuss the possible side effects of my taking strong dosages of prednisone, colchicine and ibuprofen 8 months so far and at least 6 more months anticipated? Thank you. Faride

Dr__Klein: It is true that there are some major side effects of the medicines that you mention. The most common side effect of prednisone would be fluid retention, depression or euphoria and weight gain. While on prednisone you have to make sure you are on calcium supplement and vitamin D because prednisone will make the bones osteoporotic.

The main side effect of colchicine will be GI including diarrhea and nausea. Sometimes you can get a tingling sensation and rarely alopecia. Overall - it is a pretty benign medicine - been available for over 50 years - used to treat gout.

Ibuprofen at high doses, the main side effect would be GI, trying to avoid peptic ulcer disease. It would be important that you are on PPI medications for the stomach. If being on this triple therapy is necessary, you would need to monitor kidney and liver function at least once a month.

LizG: During your previous Pericarditis chat you recommended slow weaning from Prednisone with colcrys and NSAID due to my difficulty weaning off Prednisone without recurrence of symptoms. My cardiologist agreed to Colcrys but not NSAID; concerned about GI symptoms. To date: NO RECURRENCE OF SYMPTOMS. HX: 63-yr old caucasian female. HTN well controlled. with med. Overweight. Pericarditis Feb. 2011 after flu symptoms for 3 days; mod pericardial infusion; small bilateral pleural infusions. Recurrent pericarditis 4 times. MEDS: Prednisone 6 mg QD; weaning 1 mg per month. Colcrys 0.6mg QD. Nexium 40 mg QD. Zestril 10mg QD. Maxzide 37.5mg/25mg QD. Lexapro 10 mg. Heartburn if Nexium not taken regularly. What is your recommendation going forward? Thank you so much. Your help has made a significant difference in my life!

Dr__Klein: We are happy you are doing well. I would recommend a small dose of NSAID to allow you to gradually wean of the prednisone. However, it is going to take a lot of time to get off the prednisone but so far so good.

Carp92647: I am taking the colcrys every morning and three advil, however in the morning I am still waking up with some pain. Is that normal? Is there something else I should be doing?

Dr__Klein: I would suggest checking the inflammatory markers to see if there is still activity of the pericarditis. It is possible to have pain in the chest without pericarditis. People with pericarditis are very sensitized to chest pain.

happydak: I have had pericarditis 3 times in the past 5 months as a side effect of radiation therapy. The second and third time it occurred, I developed an itchy, scratchy feeling that radiated out from my upper sternum. Are there any other symptoms I should be aware of in the early stages of recurrence, and is Feldene 10mg every day adequate to prevent it over the long term? My echocardiogram and treadmill stress test are negative.

Dr__Klein: That is a good thing that there is no pericardial fluid around the heart. Would not recommend feldene; would prefer ibuprofen 3 times a day. Follow with inflammatory markers to see if there is any ongoing inflammation.

Coal: what nsaid is the drug of choice in the recurrent pericarditis treatment? I have a Hx of peptic ulcer disease and I have tried high doses of aspirin and ibuprofen whish I have difficulty to tolerate even under protection of Protonix. Now I am on Indometacin and feel weak and drowsy. will it go away? is there are a way to manipulate doses of the Aspirin and Ibuprofen to decrease stomach side effects?

Dr__Klein: It sounds like you have a lot of questions - we would be happy to see you at the Cleveland Clinic Pericardial Center.

Surgery for Pericarditis

beadyeyed: On an average, what is the recovery time from a pericardiotomy?

Dr_Johnston: In general patients after pericardiectomy stay 5 - 7 days in the hospital and when they are discharged home, they can return to any regular exercise except that involving lifting. Recovery depends on how severe the disease was when they were treated - normally 6 - 8 weeks to full recovery, it can be longer for patients who are very ill at the time of their surgery.

gilbertazcp: My doctor said I could not have heart surgery after a sternotomy and removal of my pericardium. This was for idiopathic or viral constrictive pericarditis. He mentioned scar tissue as a reason I believe. Is that always true? Mike

Dr_Johnston: There is scar tissue around the heart after pericardiectomy and the heart is often scarred to the surrounding structures such as lungs and diaphragm and this makes surgery somewhat difficult, but not impossible. Choose a hospital with experience in this.

doliver1: I was diagnosed with pericarditis (from a viral infection) and then a pleural effusion. I was in the hospital twice for these and then once more to have the pleuordesis surgery. what are the chances of either of these two reoccurring? thank you

Dr__Klein: Roughly 20 - 30 percent of viral pericarditis can be recurrent so it is very possible that it can recur. I would suggest that you are on some preventive anti-inflammatory medications for several months after the onset of pericarditis.

gilbertazcp: Once you undergo a sternotomy to remove the pericardium because of constrictive pericarditis, can you have any heart surgery again? I am sure you can still have stents or balloons to open pathways, but is heart surgery no longer an option once the removal of the pericardium has taken place? Thank you, Mike

Dr_Johnston: Heart surgery is definitely an option after pericardiotomy. We have done a number of these surgeries with great success.

gilbertazcp: Can a person expect to have a normal lifespan after a successful operation to remove the pericardium because of constriction as long as no other health issues are present?

Dr__Klein: That is a good question. Depends on the cause of the constriction. The best survival would be from a viral or idiopathic cause. The worse would be from radiation. And the middle would be from previous open heart surgery.

SE1198: Hi, my question is about the pericardiectomy surgery. Has anyone with my profile--age 50, female, viral episode of pericarditis, no comorbidities--had this surgery? If so, what are the risks for someone with that medical profile? Thank you.

Dr_Johnston: Is there an indication for surgery. Most people with viral pericarditis don't need an operation. Do you have evidence of pericardial constriction or another reason we would operate? If there is a reason to operate then a person in their 50s with no other medical conditions would generally have a good outcome.

doliver1: I recently had a Pleurodesis performed to close a "hole" in the pleura. in your experience does surgery solve the problem for good or are there a lot of patients who have to have it done again?

Dr_Johnston: That is a complicated question - That depends on the reason for the pleurodesis. Many patients do need to have this procedure more than once.

skibuy: Dr. Johnston removed large pericardial cyst last year, health issues to watch for?

Dr_Johnston: As long as you are felling ok, there is not much to look for. It is rare for these cysts to recur, but it can happen. The good news is that they are very slow growing.

fishman: I am due for a pericardiectomy due to the calcification of the pericardium on the backside of the heart, do they have to remove the whole pericardium or just part, and how will entry be made?

Dr_Johnston: The whole pericardium should be removed in this operation although some surgeons do remove only a part of the pericardium. Our opinion is that the likelihood of recurrence is higher with only a portion of the pericardium removed. This operation can be done through sternotomy in the middle of the chest or we do incisions on both sides of the chest between the ribs - at the discretion of the surgeon.

Pericardial Effusion

Jebosley: I have a small amount of pericardial effusion that is persistent. No change in size. I also have lupus, rheumatoid arthritis and pectus excavatum. Would this small amount be from the autoimmune diseases or can it be normal to have a small amount of pericardial effusion? I have been told different things by different Cardiologists. Also, if you have effusion like this, does it mean you have pericarditis or can you have effusion without pericarditis? Thanks!

Dr__Klein: The small amt of effusion could be from your rheumatologic problems especially lupus and RA. As long as it stays small - there is really nothing to worry about it. The effusion does not necessarily mean there is active pericarditis. I would suggest having an echo every 3 - 6 months to see if it is growing in size and to make sure that the Rheumatologist treats the RA and lupus which may affect the size of the effusion.

j1966: Is having fluid around heart affected when going to higher altitude

Dr__Klein: Depends on how much fluid - if a small amount of fluid then it is of no concern.

Atrial Fibrillation and Pericarditis

mperticone: I am 47 years old and have exercised all my life. I have never been in A-Fib until I was diagnosed with Pericarditis. I am taking Multaq and Toprol to control it. Is it possible that the A-Fibs will eventually go away?

Dr__Klein: If the pericarditis is adequately treated it is possible that the afib may go away. Although if it does not go away there are medical options to treat the atrial fibrillation.

Aorta and Pericarditis

Peri_3: Does pericarditis affect coronary aneurysms, aorta or the entire circulatory system? Can it cause permanent damage to the heart?

Dr_Johnston: Fortunately it does not affect the rest of the circulatory system. In cases of severe untreated constriction there can be permanent damage.

Pericardial Sac after Heart Surgery

FromW: Given the fact that the etiology of pericarditis cannot often be identified, what may a patient who has had the condition do as a general matter of health practice to try to avoid a recurrence? Does your recommendation change if there has been a recurrence? Thank you.

Dr__Klein: As far as we know there is no major preventative measure to prevent the cause of pericarditis. Perhaps good hand washing and staying away from people who are coughing. The recurrence may occur when people taper too quickly - this occurs 20 - 30 percent of the time.

Exercise and Pericarditis

happydak: How much exercise is OK after pericarditis? I used to walk 45 minutes every day at about 4mph. Now (after chemo and radiation) I can only manage about 30 minutes at 3mph because of fatigue and chest discomfort.

Dr__Klein: It is a difficult question to answer. You should probably see your specialized cardiologist, such as one who treats patients after cancer therapy (cardio-oncologist).

Reviewed: 05/12

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