Allan Klein, MD
Allan Klein, MD

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

Deborah Kwon, MD
Deborah Kwon, MD

Tuesday, January 30, 2018 | Noon

Description

The pericardium is a thin, two-layered, fluid-filled sac that covers the outer surface of the heart. It shields the heart from infection or malignancy and contains the heart in the chest wall. It also prevents the heart from over-expanding when blood volume increases, which keeps the heart functioning efficiently. Center for the Diagnosis and Treatment of Pericardial Disease cardiologists Allan Klein, MD, Christine Jellis, MD, PhD, and Deborah Kwon, MD answer your questions.

More Information


Recurrent Pericarditis

trixmix: I had pericarditis four years ago and have not had any problems with it at all. Last month, developed chest pain and now I am diagnosed with pericarditis again! Does it always stay with you? Is this latest bout related to the first time?

Christine Jellis, MD, PhD: In our practice we do see individuals who seem more susceptible to pericarditis and show with recurrent episodes years apart. It is difficult to know the exact circumstances in your case but knowing that you are adequately treated will help prevent recurrent episodes in the future.

ReRe: 51-year-old  female, first episode pericarditis following MVR surgery 2009. Many recurrent episodes since (at least 9). All recent episodes triggered by vigorous exercise. Initial treatment 2009 NSAIDs only. 2015 treated with six mo. colchicine. Now chronic since April 2017. Symptoms more mild than previous recurrences, mild to moderate pleuritic pain upper shoulders and neck, intense fatigue. Current chronic episode treated with exercise restriction since 4/2017, three mo. prednisone taper completed 9/1/17 (first ever use of steroid, started at 10 mg bid, ended with 1 mg daily), colchicine 0.6 bid since 6/2017. Symptoms slowly improved, but mild pain still waxing, waning, at times no pain. CRP normal following prednisone despite mild pain. Cardiologist thinks maybe not active pericarditis.

Questions:
1) Am I in remission? Could pain be due to scar tissue?
2) When can I start aerobic exercise? (This is SO important to my wellbeing!).
3) How long to continue colchicine?

Allan Klein, MD: This is a complicated situation since the pericarditis is from 2009, over 9 years ago. Strongly suggest a visit to a personalized pericarditis center to get advanced imaging to evaluate the activity of pericarditis. Sometimes consideration may be given for newer anti-inflammatory medications. If you are still on medicine you are not in remission. Exercise limitations are good if you are having active symptoms. Colchicine should be continued until you are properly evaluated. If you taper the colchicine, do so very slowly - over months.

gerard: Hello from Barcelona.  I had a successful reparation of my mitral valve endoscopic three years ago but after that I had pericarditis (about eight) only two more strong. Usually one week very bad and in 2-3 more weeks I feel well again (just one had effusion) and EKG usually is ok, not the PCR....now again taken colchicine after thinking it was finished with one year free of flare ups...my question are:
1) I think by the time and colchicine the flare ups are less strong and frequent...is usually like this in cases like mine and finally usually disappears?
2) Doctors tell me is autoimmune. Is anything I can do to avoid new flare ups besides colchicine, for example i read many people with anti-inflammatory foods manage better?
3) I think sometimes for fear or somatization I get confused and I have discomforts(after 1-2 weeks of a flare up) that I would say is more anxiety than real pains from Pericarditis...Is this frequent and normal.
Thanks for your answers.

Christine Jellis, MD, PhD: We commonly see people with pericarditis which was originally triggered after cardiac surgery. This can lead to recurrent pericarditis. Although colchicine may give some symptomatic relief it may not be enough by itself to completely eradicate the inflammation and dual or triple therapy with other agents such as NSAIDs or even prednisone may be required. This should be done by a cardiologist or rheumatologist with experience in pericardial disease. The chronic nature of recurrent pericarditis can be very debilitating and demoralizing and we often see anxiety and even depression in some patients. Please make sure you are seeking assistance for your mental well-being while you address your pericardial issues.

simone91: I have had recurrent pericarditis for four years. Recently I switched docs and they had me undergo a lot of testing and found I have Lyme disease. They call this lymecarditis. Do you see this at your practice? All these years no one tested me for this.

Christine Jellis, MD, PhD: This is not something that is routinely tested for unless there is suspicion clinically that the patient could have contracted Lyme disease. An individualized approach to each patient is always indicated. Lyme disease incidence is variable depending on your location; and pericardial involvement is rare.


Idiopathic Recurrent Pericarditis

jon76: What are your thoughts about recurrent idiopathic pericarditis? Can you talk about if treatment should be somewhat different? I am on my third episode of this - very frustrated.

Allan Klein, MD: Recurrent idiopathic pericarditis is probably the most common form of recurrent pericarditis. Often it is related to a viral illness. Over 30% become recurrent after an acute episode. At our institution we see plenty of patients and can make strong recommendations of treatment. In addition, as mentioned we are doing a clinical trial with these types of patients.

indsay88: Can you talk about new studies related to pericarditis?

Allan Klein, MD: We are doing an FDA guided study on a biologic for idiopathic recurrent pericarditis. If you are interested, you can contact my office at Cleveland Clinic. The drug is called rilonacept.

Rebecca: Hello, thank you for your time today. I have had idiopathic recurrent pericarditis for four years which I'm still trying to navigate. Is it wise to take Colcrys continually (.06 mg.once a day). Also since it is recurrent, (3-4 times a year) can it over time cause damage to my heart? Thank you.

Allan Klein, MD: Having pericarditis for four years and being treated with colchicine is not that uncommon, however you should probably be evaluated to see if other medicines can be added to the colchicine if the pericarditis is resistant. If the pericarditis is under control, you can try to gradually wean the colchicine. Things to watch for with the colchicine are hair loss, neuropathy and GI symptoms. At Cleveland Clinic after 3-4 years for intractable cases, we are evaluating the use of pericardiectomy for these patients.


Chronic Pericarditis

kennedy88972: I have chronic pericarditis. At the end of last year I was hospitalized for two times with pericardial effusion. Is this a progression of the pericarditis? My doctor is going to do a biopsy - what are you thinking? Is this common with pericarditis?

Allan Klein, MD: Pericarditis with pericardial effusion is common. Treatment should be directed towards the pericarditis and often the effusion improves. A biopsy could be considered but may be low yield depending on the circumstances. If the effusion is very large, therapeutic techniques such as a window with the biopsy or pericardiocentesis could be done. I would suggest an evaluation at a center for pericardial disease.


Autoimmune Conditions, Rheumatoid Arthritis, Lupus and Pericarditis

yannip: If you have pericarditis and your blood work comes back that you may have some type of autoimmune condition - are there any special diets or supplements to take related to the autoimmune part?

Christine Jellis, MD, PhD: We always advocate a well-balanced healthy heart diet for all patients with cardiovascular disease. We would target pharmacologic therapy toward the underlying rheumatologic condition along with our rheumatology colleagues.

ruthieuk: What is the relationship between rheumatoid arthritis and pericarditis. My mom has RA and I just had an episode of chest pain - doctor told me it is pericarditis - and wants me to see a rheumatologist?

Christine Jellis, MD, PhD: There is a link between pericarditis and autoimmune disease. Rheumatoid arthritis can also be more prevalent in certain families. It would be reasonable for you to see a rheumatologist to be evaluated further. However if your chest pain is persistent, then it should be evaluated further and a cardiology consultation is suggested.

bunny2: My daughter had severe chest pain. Went to hospital found she had low BP. Has a history of lupus. Is this all related together? What should I expect for treatment?

Christine Jellis, MD, PhD: Certainly there is a known link between pericarditis and lupus, so we would encourage your daughter to be further evaluated. Treatment will depend on her clinical features. There are many reasons why her blood pressure may have been low and I would suggest she seeks an evaluation by a cardiologist who has a special interest in pericardial disease.


Medications

KKthomas: Could it be that colchicine is wreaking havoc on my stomach? Any suggestions?

Allan Klein, MD: Definitely colchicine will affect the GI tract. One suggestion would be to go on the lowest possible dose such as one tablet once a day or 1/2 a tablet once a day. Other side effects to watch for are hair loss and neuropathy.

frank: I have had pericarditis for a month - on ibuprofen, colchicine. How do you know when it is time to wean down on drugs and that you are getting better. I have less chest pain, still short of breath but maybe I am just weak from not doing anything. How long does it take to wean and then feel better?

Allan Klein, MD: For acute pericarditis, the weaning should be gradual over another month. This would be important to prevent it from becoming recurrent. Most cases of pericarditis do resolve with standard therapy.

rosemarievv: I have been on Advil for two months for pericarditis. I read online about regimens of colchicine, ibuprofen and prednisone. My doctor told me to stay on the Advil and that I do not need the colchicine. What is your recommended regimen of drugs?

Deborah Kwon, MD: Typically we give both ibuprofen and colchicine unless contraindicated or if your case is mild - or if you are responding to the ibuprofen. Our recommendations for treatment with anti-inflammatory medications depend on the severity of inflammation.

kwillia1: I had an episode of pericarditis in July, 2017, after contracting a virus. I could not tolerate the recommended medication, Colchicine. After one month of severe dehydration and diarrhea, my primary MD put me on mega doses of aspirin, which I stayed on for two more months. I plan to travel out of the country and am concerned that if I over-exert or pick up another virus, I might have another episode. Would you recommend starting treatment with the Colchicine? Would going straight to aspirin work?

Christine Jellis, MD, PhD: Diarrhea in the setting of colchicine may reflect colchicine toxicity. If you are currently asymptomatic we would not advocate commencing treatment prophylactically however if you do develop another flair of symptoms, it would be reasonable to medicate with high dose aspirin and seek medical assistance during travel. If you need additional therapy we would suggest trialing colchicine at a lower dose this time. Travel can potentially aggravate the pericarditis so amount of activity may need to be limited.


Surgery for Pericarditis

laylamc: I have pericarditis and my doctor wants me to have part of my pericardium removed - I have been reading online and wonder how do they decide to have some of the pericardium removed (is that a window?) or all the pericardium removed? Also - are there problems long term to live without your pericardium?

Allan Klein, MD: I would question the surgery. There are different types of surgery that can be done for pericardial diseases including a pericardial window; a partial pericardectomy; or a radical pericardectomy. You may want to consider coming to a center that has expertise in all of these and to see if they are indicated for your condition.


Flu Shot and Pericarditis

jj2245: Doctors - I have been hesitant to get a flu shot this year due to my immune system and inflammation - but on the other hand nervous about the flu. What are your thoughts?

Allan Klein, MD: We would encourage you to get the flu shot since an active flu could exacerbate pericarditis.


Continuing Symptoms

Léia: I’m 36 and was healthy until I had felt palpitation and unspecific sensations in the chest for some months. The echo showed moderate pericardial effusion, with a greater 20 mm blade. MRI showed no signs of constriction. The CRP and research of collagenoses came all negative. Coxsackie B sorology was positive. After no improve with ibuprofen, colchicine and prednisone, it was chosen to perform pericardial window by video thorocoscopy. Pericardial biopsy showed non-specific chronic pericarditis with submesothelial fibrosis. Echo after six months showed discrete pericardial effusion. Eventually I again experience bouts of palpitations and weight in the chest as if it had a band around the thorax and making it difficult to exhale. These symptoms usually last up to 20 minutes. Is it possible to have recurrent episodes of pericarditis even with negative CRP, with no significant pain, and practically normal echo? Should I use colchicine to avoid these bouts and other complications?

Deborah Kwon, MD: Typically pericarditis results in elevated inflammatory markers particularly if you are not taking any anti-inflammatory medications at the time. Therefore if testing does not demonstrate elevated inflammatory markers abnormal EKG or pericardial effusion on echo, then it is unlikely that pericarditis is the reason for your symptoms. I would recommend further assessment by a cardiologist to determine the cause of your symptoms and need for medication.

jackinbox: I have pericarditis and my chest hurts worse when I lie down. This is making it hard for me to sleep. Any suggestions?

Deborah Kwon, MD: If you have been diagnosed with pericarditis, you should be on anti-inflammatory medications. You should contact your physician about your continued symptoms as your medication regimen may need to be adjusted.


Diet and Supplements

mariaK: If pericarditis is related to inflammation, would it help to take things like fish oil, vitamin C or coenzyme Q10 to help with decreasing inflammatory responses?

Christine Jellis, MD, PhD: While these agents have been shown in other conditions to have some anti-inflammatory properties we do not have hard data to support their use in pericarditis. And typically more traditional therapy such as colchicine, NSAIDs and prednisone for anti-inflammatory therapy is used. Sometimes the Mediterranean diet may be beneficial due to anti - inflammatory properties.

Reviewed: 02/18

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