Allan Klein, MD
Allan Klein, MD

Christine Jellis, MD, PhD
Christine Jellis, MD, PhD

Deborah Kwon, MD
Deborah Kwon, MD

Tuesday, October 24, 2017 | Noon

Description

Pericarditis is an inflammation of the pericardium, which is a thin, two-layered, fluid-filled sac that covers the outer surface of the heart 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, Dr. Jellis and Dr. Kwon answers your questions about pericarditis and other pericardial conditions.

More Information


Pericarditis: Causes

Deeginn1: I was diagnosed this August with Pericarditis. I had an Echo with no effusion noted. I had all blood work and x-rays come back with no findings. The ER doctor who diagnosed me had applied 2/4 criteria of hearing the RUB and the proper EKG changes/ elevations and depressions.

I was prescribed Colchicine for 28 days and ibuprofen. When I finished the Colchicine I went back to my GP and she said no refill on the Colchicine because that is only for recurrences. In the mean time I have had the Pericarditis still flaring. The ibuprofen helps a lot to maintain but if I taper any lower than 1600 mg a day I get a flare. I have an appointment with a Rheumatologist this Thursday. I have psoriasis and Uveitis (eyes). Why do you think my Pericarditis hasn’t subsided yet? If is autoimmune related will there be a prescription for me so it helps it to clear?? Thanks I’m advance for your help.

Allan Klein, MD: It is not clear whether you had a viral illness that precipitated your initial attack. However, by history, you have several autoimmune features including psoriasis and uveitis. It may be very important to see a rheumatologist to decide whether you have an autoimmune disease and secondary pericarditis. The rheumatologist would need to treat the autoimmune disease. In the meantime, we recommend continuing on the ibuprofen and colchicine. We would be glad to evaluate you here at Cleveland Clinic


Pericarditis: Diagnosis

chevy66:  What are the tests that need to be done to verify pericarditis - what specific markers or testing?

Christine Jellis, MD, PhD: Usually we start with echocardiography to evaluate for pericardial effusion and lab tests including ESR and CRP to establish if there is underlying inflammation. Sometimes a cardiac MRI provides further information regarding active inflammation or longer term consequences such as constriction.

DShort:  I know my pericarditis diagnosis is not as clear as most. Because I have slight septal bounce, trivial effusion, SOB on exertion, elevated HS CRP, and have had Rheumatoid Arthritis for many years, how do you distinguish between other issues that may be beginning, such as heart failure or pulmonary hypertension? Would all these other diseases be easy to diagnose in early stages, or would they look a lot like pericarditis, or beginning constrictive pericarditis? The most concerning thing for me is, this came on suddenly, has lasted for 3 years now, and does not seem to be going away even with total rest, meds etc. I am unsure what to do going forward. I tend to worry a LOT because this diagnosis is not clear-cut. Thank you.

Deborah Kwon, MD: It sounds like your cardiac condition is complex and it is difficult to discern through this web chat. We would be happy to offer you a comprehensive evaluation at Cleveland Clinic which would include an echocardiogram and possibly further testing if needed. A rheumatology consult would also be highly recommended and could be coordinated during your visit.

sinaihospital: I have pericarditis. Once it was diagnosed by former cardiologist. What Is the tests & treatments for pericarditis? Doctors? Thank you for your advice.

Christine Jellis, MD, PhD: If it has been some time since you have been seen, we would advise a face to face consultation, with targeted imaging and lab testing to determine if you have any evidence of current active pericarditis or constriction as a consequence of your prior pericarditis.

Deeginn1:  If I already have psoriasis for over 45 years and newly diagnosed with pericarditis how likely is it my pericarditis is autoimmune related? Thanks.

Allan Klein, MD: Likely.


Pericarditis: Symptoms

echenberg:  Shortness of breath on exertion increasing since June 2 016. January 2017 inferior MI with total right coronary occlusion. February 2007 perforation of right coronary during stent leading heml pericardium &pericardial effusion. Because of persistent shortness of breath I had a triplebypass and three stents. I continued to have extreme shortness of breath even walking a few steps. Finally diagnosis of pericarditis was made and was started on indomethacin and colchicine. Symptoms have improved slightly but continued to have shortness of breath on exertion, e.g. walking across a room. The only time I had pain was in the hours subsequent to the coronary perforation. I had to DC the colchicine because of peripheral neuropathy. Still very symptomatic.

Deborah Kwon, MD: You need further assessment for possible constrictive pericarditis as a complication - we would be happy to evaluate you further.

Allan Klein, MD: Also consider switching your indomethacin with high dose aspirin given your history of CAD.

CollinsJJ: I have pericarditis that is recurrent. For the past three weeks I have had a chest infection, coughing, pain in the chest. They said it is viral and just treating the symptoms. But could it flare up my pericarditis? Are there things I should do or look for to prevent this - the pain is uncomfortable but I think it is related to the chest infection - I think?

Allan Klein, MD: For somebody with recurrent pericarditis, a recent chest infection could possibly flare the pericarditis. Often we tell patients to continue their anti-inflammatories during those episodes. If they are not on anti-inflammatories they may have to resume a small dose of an NSAID during those episodes.

Jeff28: I had pericarditis last year. It took about six months to completely go away - I think it is gone. Recently I have had palpitations or feels like fast heart rate. Could that be from the prior pericarditis? Is this a symptom that it is back?

Christine Jellis, MD, PhD: Sometimes there can be an association between cardiac inflammation and arrhythmias, although sometimes arrhythmias occur in isolation. I would advocate evaluation for underlying recurrent pericarditis, but also a cardiac monitor may be helpful to document if you are having ectopic beats or sustained arrhythmias. We would be happy to see you here in our clinic to provide this evaluation.

Girl 43: Could my monthly period cause my symptoms to flare up more?

I’m 43 and was diagnosed with pericarditis August 23, from the flu. I feel like a week before my monthly, I seem to take a step back from my recovery, or this is in my head, because I’m just so darn tired. I just feel like my heart is resting faster and the stabbing that had started to go away seems more frequent during this time of the month. Thank you

Christine Jellis, MD, PhD: Sometimes general fatigue and hormonal changes can exacerbate concurrent medical problems. It may be that this is a factor in you. It sounds like it would be important to ensure that you do not have underlying sub-acute pericarditis which should be treated. I would advocate you seek further evaluation from a cardiologist with a special interest in pericarditis.

CherylB: My daughter (20 years old) was diagnosed with pericarditis just over a year ago. Since then she has had ongoing severe debilitating pain although no evidence of current pericarditis. Her CRP has never been raised, but she had fluid, the rub and ECG changes. She has recently had a biopsy taken of her pericardium and a small amount of fluid drained. There was evidence of past pericarditis but nothing came up in the biopsies. Interestingly, her pericardial pain has almost disappeared since the surgery last week, although she is still on strong pain killers after the surgery.

My questions are:  Can the pericardial pain remain even though technically the pericarditis has resolved? Can pericarditis lead to chronic pain? She has pain in her upper back (left side) and her sternum is very tender to touch.Are you aware of cases where continuing pericardial type pain is actually muscular, skeletal or has other origins? Thank you for helping us find answers for our daughter.

Christine Jellis, MD, PhD: In some cases, pericardial inflammation is a sign of wider spread autoimmune/inflammatory disease. It may be that her pericarditis is resolved, but she has other residual inflammatory foci such as costochondritis. If a rheumatology opinion has not been sought yet - it may be considered.

Allan Klein, MD: In the meantime, post biopsy she should remain on her NSAIDs perhaps until her pain improves.


Pericarditis Post MI

manenamiller: Hello, my 50-year-old husband suffered a massive myocardial infarction that left him with only 1/4 of his heart working. 100% blockage on left coronary artery for 12 hrs. Only 20% ejection fraction. Never suffered from high blood pressure or high cholesterol. Very active individual. He was diagnosed with Post M/I pericarditis and given meds while he was at the hospital. However, none of the medications given to him after he left are for pericarditis.

How do we know that he is not having pericarditis any longer? What symptoms should he have if that would be the case?
Thank you

Christine Jellis, MD, PhD: in general most cases of post MI pericarditis resolve without further exacerbation. If he were to be having underlying pericarditis usually this would be symptomatic with chest pain on inspiration or shortness of breath. If he is otherwise doing well, and his echoes have been unremarkable for pericardial effusion, it does not sound like he has active pericarditis.


Chronic Pericarditis

Jon27: Recently diagnosed with chronic Pericarditis due to Rheumatoid Arthritis with organ/system involvement and Sjogrens. RF Screen, Quant. = 160.5 IU/mL (Range = 0 – 13.9 – Test exceeded linearity and result was based on specimen dilution) ANA Titer = >1:1280 (Range = 1:160, >1:160 = high antibody) ESR, Automated = 27MM/HR (Range = 0 – 19) SS-A AB = >8.0 Al (Range <1.0 = negative), result = abnormal. Recently passed a nuclear stress test. Should other testing be considered for diagnosis or is diagnosis final? What should I expect in the future? What I can do to help myself going forward?

Allan Klein, MD: First of all, the rheumatoid arthritis should be treated by the rheumatologist to prevent further attacks of pericarditis with meds such as plaquenil. If the pericarditis is autoimmune, this would be a longer term process.

echenberg: How common is chronic pericarditis (or myocarditis) where the presenting (and ongoing) symptomis dyspnea on slight to moderate exertion and with no chest pain.

Deborah Kwon, MD: Usually when there is pericarditis there is chest pain but typically when someone presents shortness of breath, we will do an echocardiogram which can determine if there are other causes for their shortness of breath.


Pericarditis in Children

Taryn: Hello, our 11-year-old son has been suffering from pericarditis for four years. He is suspected of having an autoinflammatory disease and we are waiting on WES results. He's had small effusions but usually there is none. His last MRI showed mild inflammation and minor adhesions. His CRP and ESR have only been elevated a few times. His pain is severe even when these labs are normal. He failed to respond to Ilaris and Kineret. He is currently on Colchicine, Naproxen, and Ranitidine. Cardiologist just added Metoprolol to help keep his heart rate down. His painful flares last weeks to three months. How long should he stay inactive for? In the past we were told once he felt better he cold resume sports, I think that was the wrong advice as he's been getting worse as years progress. We were also told surgery may be an option. We are desperate to find a solution for his pain and fatigue. Thank You, Taryn

Christine Jellis, MD, PhD: This is obviously a complex and difficult situation. Management of pericarditis in pericarditis is a subspecialty area. We would advocate that he should be seen by pediatric rheumatologist and a pediatric cardiologist with subspecialty interest in this area.

Deborah Kwon, MD: For now he should be limiting his activity with active inflammation as this can exacerbate symptoms.

Allan Klein, MD: You should be evaluated at our Center of Excellence. You can contact me and I can facilitate evaluation with our pediatric team.


Medications

Alaska123:  Hello, my second bout with pericarditis and symptoms remain unchanged for eight months. 0.6 Colchicine, a PPI and 2400 mg ibuprofen daily. If I attempt to skip or lower a dose of ibuprofen the pain returns within two hours. Unable to do anything which brings my heart rate up or symptoms worsen. My Dr tells me to be patient, that "it will burn itself out". I'm concerned about long term use of ibuprofen. Time to change doctors? We're very limited on specialists in Alaska but I'm willing to travel.

Allan Klein, MD: You should probably travel to our center to get you on a stable regimen of your anti-inflammatories. Unfortunately if you taper too quickly - this can return. You may need additional testing to evaluate you further, such as cardiac MRI.
We see many patients from a distance. After your initial consultation, we can often follow patients with a virtual visit.

Jon27:  Does the following treatment sound right? 0.6mg of Colchicine 2x/day and 400mg of Advil 2x/day (Advil for the next month).

Allan Klein, MD: That is good treatment however, the rheumatologist should decide how they want to treat the rheumatoid. Also recommend slow taper of the meds you mentioned - first advil, then colchicine

ben22593: What if someone cannot take ibuprofen - what are the choices in medications during a pericarditis flare up?

Christine Jellis, MD, PhD: Colchicine is often a useful agent . High dose aspirin can be used but may have similar side effects to ibuprofen.

Deborah Kwon, MD: If these are not effective, then prednisone can be used.

meggietoo: Can you talk about the newer medications or treatments for recurrent pericarditis - and when you should start looking at those vs. other medications? My current course of medications (ibuprofen and colchicine) is not working - How long do you go on your meds before you think they have failed and move on?

Christine Jellis, MD, PhD: If your symptoms have persisted despite colchicine and ibuprofen for several months or if you are having recurrent episodes it would be reasonable certainly to try triple therapy. Traditionally this has included prednisone, but now newer steroid sparing agents such as azathioprine or anakinra, are being increasingly used. Typically these are prescribed by a rheumatologist.

ruby:  When flare-ups subside - what medications should you be on "forever" to prevent future flare ups? What type of follow up and testing should you undergo?

Allan Klein, MD: We do not recommend medications forever, however what you are taking should be gradually tapered off and inflammatory markers should be checked to see if there is any active inflammation.

acesneights41: I was just released from hospital with second flare up of pericarditis. Although I don’t think I have ever got rid of it. I have been on colchicine and indomethacin for over a year. My echo showed a small effusion and my MRI showed slight thickening. My CRP was elevated but sed rate is normal. They have now put on prednisone, but I don’t like the idea of steroid. I have MS and I have had some bad reactions to steroids. Any suggestions?

Christine Jellis, MD, PhD: Long term steroids can certainly be problematic. Consideration of steroid sparing agents may need to be made. Although this should be in conjunction with rheumatology and your neurologist. If you are already on steroids, make sure any dose reductions are done slowly to avoid precipitation of flare-up.

leeds22: Five year history of idiopathic (viral) auto-inflammatory chronic pericarditis. On colchicine, eterocoxib, methotrexate hydroxychloroquine and ivabradine. Improvedbut ongoing symptoms chest pain with very limited exercise tolerance and intermittent effusion. CRP not and never has been raised. Would anakinra be likely to be effective in this case?

Allan Klein, MD: It is interesting that the CRP has never been elevated. This may represent suppression by the combination of anti-inflammatories. This case may benefit from assessment with cardiac MRI to see the target. If there is ongoing inflammation, anakinra can be considered. We would recommend being evaluated here at our Pericardial Center.

leeds22: Further to my initial question regarding anakinra with a normal CRP a MRI showed thickening to 6 mm two years ago, but three months ago this thickening had resolved. I still get intermittent effusions by echo. Does the normal MRI mean anakinra is unlikely to be effective?

Allan Klein, MD: It is possible that anakinra is working if it resolved the thickeningI would suggest if the symptoms are better on the anakinra that you should maintain on it. Overtime - this can be tapered slowly.

jdelacruz: Thank you for taking the time today to answer questions today. I have been taking colchicine and aspirin for about a year. I had no symptoms at around 11 months and came off of the meds. Three months later symptoms returned. I am now back on the colchicine and aspirin but have since asked my cardiologist to change my aspirin to another NSAID since it doesn’t seem to be working after two months. I am allergic to ibuprofen (I get swollen lips) and so i was given aspirin at first. Now I am trying Indocin. Is there a specific NSAID that seems to work better than others? Is Indocin close to the top of that list?

Christine Jellis, MD, PhD: NSAIDs as a group can be effective but the key is making sure that you are on a high enough dose. If you have persistent symptoms on NSAIDs and colchicine then consideration should be made to be on triple therapy with prednisone or steroid sparing agents.


Medications: Tapering

Orgelr269: It is my first time being diagnosed with pericarditis, I have had it for about three weeks. My doctor has me on Celebrex once a day and colchicine twice a day, in the third week the pain is now at a minimum and only comes for about 30 min. at a time once every day or two days and is way less intense. I am concerned that once we lessen the medications (which my cardiologist suggests doing in a week) it will get worse again, what should I expect? I am also concerned about reoccurrence, what can I do to limit the chances of getting pericarditis again in the future? I have started looking into an anti-inflammatory diet, can that help? Thank you, also I am a 27-year-old male.

Allan Klein, MD: I would recommend continuing the medicines longer, follow the CRP and sed rate (ESR) and a very gradual taper of the medicines. If there is a flare on these medicines, the doctor may have to consider having another medicine such as prednisone or other steroid sparing medication.

jdelacruz: After symptoms have subsided for a month, is it recommended to stay on a lighter dose regiment of colchicine and aspirin? Would you also recommend starting an anti-inflammatory diet routine and sticking to it forever?

Has there been any studies or instances that you know of which might link pericarditis to low calorie and/or low carbohydrate diets? I've had two bad bouts and both seem to coincide with me being sick and being in a caloric deficit while using low to no carb diets. I am a healthy 200lbs 6'3" 39 year old male that has been dealing with pericarditis which caused some myocarditis since my first bout almost a year and a half ago. This last bout did not produce any raised troponin levels like the first one did so my Dr. doesn’t seem too worried. I tend to believe and he might agree that the anxiety I get from the symptoms is doing more harm than the actual disease.

Allan Klein, MD: I would continue both the same dose of colchicine and aspirin and with gradual tapering first with the aspirin and then the colchicine to prevent the next attack. I do recommend a Mediterranean diet with a lot of fish and vegetables. Would not recommend a major change in diet while treating the myo pericarditis.

Deeginn1: After being diagnosed in the ER with Pericarditis the ER doctor prescribed Colchicine for 28 days and IB- after the 28 days my GP would not refill the colchicine and said that would only be for a recurrence? But I told her I still have the pain when I try to taper the IB- so it doesn’t make sense to me? Thank you!

Deborah Kwon, MD: We typically give colchicine in conjunction with the ibuprofen with a slow wean of both.


Diet and Exercise

RebeccaL: Since pericarditis is linked to inflammatory processes - do you recommend any specific diet - such as an anti-inflammatory diet?

Deborah Kwon, MD: Currently there is no evidence to support dietary restrictions at this time. But there is evidence to support the Mediterranean diet can be beneficial for all types of cardiac conditions.

Jerry88: Dr Klein, you have mentioned before doing no exercise while having a flare-up - can people actually go back to exercising once the flare up is gone - During the flare-up is it ok to do anything? The lack of activity is killing me? And then when this goes away (I hope someday) can I go back to my full exercise or do you still limit it?

Allan Klein, MD: We follow the recommendations from the European Society of Cardiology - no significant exercise for six months if they are an athlete. Most people are able to return to exercise once they wean off their anti-inflammatory medications. We do not recommend exercise during active flare. Often we recommend walking to keep the heart rate less than 100 bpm. The exercise seems to aggravate the pericarditis.

Alaska123: Would you recommend CBD oil for pericarditis? Or any other supplements which may ease inflammation?

Christine Jellis, MD, PhD: There is no current evidence for the use of non-FDA approved anti-inflammatory therapy for use in pericarditis.

Orgelr269: I am wondering also if exercise could maybe be good for pericarditis once you are starting to feel better after 2-3 weeks of colchicine. I have been anxious to start running again and playing hockey but I also don’t want to keep missing exercise.

Allan Klein, MD: I can sympathize with you regarding the hockey however the pericarditis is like a scab on the heart and it has to heal. Therefore the exercise including hockey and running may not be the best thing until it heals.


Surgery for Pericarditis

acesneights41: When do you consider pericardiectomy since I do have thickening.

Deborah Kwon, MD: We only consider pericardiectomy when either there is constrictive physiology and no active inflammation - or - if the pain is refractory to all medication. Thickening in of itself is not an indication for pericardiectomy as this can resolve if the pericarditis is adequately treated.


Closing

Moderator: Thank you for all the questions this afternoon. This concludes our chat for this afternoon. Please feel free to join any of our other upcoming web chats by visiting clevelandclinic.org/webchat.

Allan Klein, MD: We thank you for participating in the web chat. At the Cleveland Clinic, we have a multi-disciplinary Center for the Diagnosis and Treatment of Pericardial Diseases. This center specializes in treatment of pericardial diseases similar to what has been discussed in this web chat and we would be happy to evaluate you in the future.

Reviewed: 11/17

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