Allan Klein, MD
Allan Klein, MD

Tuesday, October 23, 2018 | Noon


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. Allan Klein, MD answers your questions about pericarditis and other pericardial conditions.

More Information

Persistent Pericarditis

Elinore: I have been diagnosed with persistent pericarditis. I currently take .6 mg of colchicine twice a day. I use over the counter pain meds sparingly to help with the chest pain. After 1 1/2 years of treatment my echo finally shows no fluid. I guess I expected the chest pain to subside when that occurred but I notice no change. My chest hurts daily. I just haven’t asked my cardiologist if persistent equates to for the rest of my days. Does persistent pericarditis ever go away? What are recommendations for management if the chest pain? Thank you for this opportunity to ask my questions.

Allan Klein, MD: It is time for you to see a pericardial specialist to evaluate what is causing your pain - is it chronic pain or actually active pericarditis?

Elinore: Morning, I developed pericarditis two years ago. It was classified as idiopathic. At first I was told it was chronic and now they refer to it as persistent. The rub has never gone completely away. I currently take .6mg of Colchicine twice a day and manage chest pain with over the counter pain medication. Will it ever go away? If it doesn't, what implications does that have for my future heart health?

Allan Klein, MD: You need to be seen by a pericardial center. This is very common and it is very important to evaluate if there is ongoing inflammation.

Causes of Pericarditis

TinaRae: Even though the expected cause of my Pericarditis was viral and not an autoimmune disorder, it has caused an ongoing immune response. Should I still be seen by a Rheumatologists or someone who specializes in inflammation? If the Virus has run its course, and my body is still reacting via inflammation, I am questioning if a physician specializing in the treatment of inflammation would help being added as a provider along with cardiology?

Allan Klein, MD: You should be seen both by a pericardial specialist and rheumatologist to make sure there are no auto-immune features. The most common cause of pericarditis is viral, which causes auto-inflammation and activation of the inflamasome. Sometimes there is a genetic basis for the exaggerated inflammatory response. We work very closely with our rheumatologists at Cleveland Clinic.

ssbronx: In case my question wasn't received earlier: My 42-year-old husband contracted viral pericarditis with 2-3 cm of fluid which was managed by colchicine and ibuprofen. It took him about six weeks to fully recover and the worst part was some intense bouts of Afib. He's back to good health and normal activities and has tapered off metoprolol. Is there anything we can do to make sure this never comes back and do you think he has Afib as a permanent condition now?

Allan Klein, MD: The afib is most likely from the pericarditis. A very slow taper of the anti-inflammatories is necessary. If you taper too quickly it can come back.

Diagnosis and Diagnostic Testing

TinaRae: My reaction to the MRI Gadoterate Meglumine has become an issue. What are my alternatives?

Allan Klein, MD: I would have to check to see if there are any alternative dyes.

Nurse2: This question pertains to unexplained abdominal manifestations in a patient who has been diagnosed with complicated pericarditis. I've read that right sided heart failure can present as an "abdominal syndrome" with bloating, loss of appetite, abdominal tenderness, sometimes n/v and weight loss.  How is this evaluated when a person has been taking prednisone and has had weight gain, but yet reports all other complaints?

Allan Klein, MD: You need a good clinical examination combined with an echo to sort this out. You would look at the JVP on examination and the size of the inferior vena cava on echo.

Justbreathe: If the person is having active flares but their CRP markers are normal, do you "stay the course" for a certain amount of time? Doesn’t the prednisone skew the results of the markers so therefore they may not be accurate?

Allan Klein, MD: Once they go on prednisone, the markers may not be reliable. Therefore you need to look at other things such as a good clinical exam, echo to assess effusion, MRI to assess residual inflammation. All of these things go into the equation.

Medications of Pericarditis

acesneights41: I have been battling pericarditis for two and a half years now we have tried very slow tapering off Prednisone I also have MS so I occasionally have to have infusions of steroids I'm concerned about the steroid use because I have already had a pathological fracture to my foot I'm on 10 mg of Prednisone colchicine and indomethacin and that seems to work but I still have flare-ups and I was wondering if there's any other kind of treatment or what you think of the treatment and kineret. My cardiologist thinks that as long as I can control my CRP levels and my pain at 10 mg of Prednisone into the center in cultures eat daily that that should be enough but I am afraid of the side effects.

Allan Klein, MD: I agree with you that if you are having side effects of prednisone you will need a fourth agent - either a Dmard like imuran or a biologic like anakinra.

Lakers987: I have had pericarditis since early 2017. I was placed on prednisone after being diagnosed WITH pleural pericarditis effusion. I was able to get off prednisone within 10 months and indomethacin after 8 months. Still on colchicine though after 18 months .6 2X DAILY. LAST 6 months no elevated CRP or SED RATES. Why do you suggest?

Allan Klein, MD: I would recommend a very gradual taper of the colchicine to once a day and then 1/2 a dose and then every other day while following inflammatory markers.

TinaRae: What do I need to do to avoid the need for Steroids? I very much do not want to go there.

Allan Klein, MD: We would need to know more about your pericarditis history. Steroids are not first line therapy.

Justbreathe: At what point do you determine that triple therapy is not working? In other words, how will it know when it's time to consider another drug as treatment?

Allan Klein, MD: We know it is not working when there are active flares with elevated markers (US-CRP, CRP, WSR, d-dimer); worsening of the MRI. These indicators would show that it is time for another drug.

Justbreathe: If someone with recurrent chronic pericarditis is experiencing many many effects from it, how long do you continue to keep that patient on the prednisone before deciding to switch to the other drugs? Does the prednisone have to continue to be tapered down completely before it is replaced by the other drugs or are they started right away while the prednisone continues to be tapered? What are the major risks of the other two drugs and how do you decide which one to prescribe?

Allan Klein, MD: You start with another drug for around a month, like imuran, and then you start to gradually taper from the prednisone. It is a very slow process. Each of the drugs have side effects but they are probably less than the side effects of prednisone long term. Usually the dmard is the next drug; and anakinra would be the last drug. Unfortunately insurance companies are not forthcoming with anakinra and you need to see a rheumatologist to support the need for this medication.

dhs123: I am a 61-year-old male with pericarditis, after pacemaker lead implant surgery (for bradycardia - with a history of bundle branch block). The implant surgery (on 8/27/2018) caused some level of perforation with a cardiac tamponade 8/28/2018 (bloody), a subsequent pericardial effusion (9/2/2018) (mostly serum). Pericardiocentesis was performed for each. Pacemaker functioning normally. Diagnosed with pericarditis on 9/2/2108 with Afib. (Afib cleared up after 4 days - have had intermittent bouts of Afib a few hours at a time 3 times since). Started Indomethacin 25mg 3X, Colchicine 0.6 mg 2x on 9/2/2018, increased to 50 mg 3X 1 week later, switched to ibuprofen 800mg 3x daily 3 weeks later due to chest/shoulder pain. Colchicine, Pantoprazole, Metoprolol maintained throughout. Pain has decreased largely and fever is gone since a few days after the switch to ibuprofen. When should the ibuprofen be tapered down, and what should the tapering schedule/tests be?

Allan Klein, MD: A case like this needs to be seen by a pericardial specialist where we would look to see if there is still active inflammation. Prolonged tapering of ibuprofen will be needed; followed by the colchicine.

Justbreathe: How long is the typical patient on triple therapy? How do you initially determine the proper dose of ibuprofen? Is it based on body weight or the severity of symptoms?  If a patient had an elevated creatine level and has to take a lower dose of ibuprofen (while taking prednisone and colchicine), is it still enough/ as effective as the preferred higher dose?

Allan Klein, MD: Often triple therapy is prescribed only for advanced cases of complicated pericarditis. The cardiac MRI with a pericarditis protocol often determines how many drugs, for how long and prognosis. If the MRI shows severe inflammation on the baseline visit at Cleveland Clinic, we can predict how long it will take to be on the drugs. People do get better but can take months to years. All the doses can be adjusted.

Lakers987: I have had pericarditis since early 2017. I was placed on prednisone after being diagnosed WITH pleural pericarditis effusion. I was able to get off prednisone within 10 months and indomethacin after eight months. Still on colchicine though after 18 months .6 2X DAILY. LAST 6 months no elevated CRP or SED RATES. Why do you suggest?

Allan Klein, MD: I would recommend a very gradual taper of the colchicine to once a day and then 1/2 a dose and then every other day while following inflammatory markers.

Pericarditis and Surgery

hogs: I had a pericardiectomy at CC on April 10, 2018. What should I be doing or not doing now - six months later?

Allan Klein, MD: You should check with your cardiologist how you have done since the pericardiectomy and he can give you an exercise program.

Pericarditis and Rheumatology Conditions

Sunday: I was first diagnosed with pericarditis in 1996! I had a pacemaker placed and had been very ill for a year prior! After two weeks of pericarditis, I had two liters of non-clotting blood around my heart! Tamponade then has a pericardial window done! I suffered with pericarditis for another year! I continued getting it so often I would just treat myself with 800 mg of Motrin and not seek medical care! Twenty six years later I've been diagnosed with sle lupus! I have pots among other health issues! I'm positive for anti da dna! I still get pericarditis and small pleural effusions and pericardial effusions! Other than the lupus treatment is there anything I could do to prevent the pericarditis! I have runs of NSVT, afib, svt and have been diagnosed with congestive heart failure due to diastolic failure! I have mild thickening of the pericardial lining and calcification!! Should I be under additional treatment? I'm improving since on meds but I get chest pain.

Allan Klein, MD: You definitely will need to see a cardiologist and most likely a pericardial specialist for your heart condition and lupus. We would be glad to see you at Cleveland Clinic.

Pericarditis and Heart Surgery

dlinton14: 1) I had a mitral valve repair via a minimally invasive procedure using a right thoracotomy, including the insertion of a 33mm ring. My condition of pericarditis was judged to have stemmed from that procedure. How could the pericardium be affected as the procedure was performed through an artery/vein? Doesn’t the artery/vein pass through the pericardium?

Allan Klein, MD: Even with a right thoracotomy the pericardium has to be opened. And thus, pericarditis can develop.

adourian: I had very successful open heart surgery at CC (aortic valve bioprothesis & ablation) a year ago with few complications post surgery. Those that I had were related to transient rhythm issues. I recall being told that the pericardium was not closed after surgery to avoid the potential for fluid buildup which would create undue pressure on the heart. Am I more susceptible to pericarditis as a result? Are there any other considerations i.e. types of exercise to avoid as a result? Does the pericardium close up after a period of time?

Allan Klein, MD: I think one year after surgery, you should not worry about getting pericarditis from the surgery. At this point you are not more susceptible for pericarditis. Leaving the pericardium open after heart surgery is not a concern.

Constrictive Pericarditis

Nurse2: How would you know if someone with chronic disease is developing constrictive physiology? Are there early warning signs?

Allan Klein, MD: Constrictive physiology without clinical constriction is often observed on an echocardiogram. Often patients may not manifest clinically. However, early treatment with anti-inflammatories may help prevent the clinical syndrome of constrictive pericarditis.

Nurse2: Can you develop heart failure pericarditis, and how would you know.

Allan Klein, MD: This is called constrictive pericarditis. It causes symptoms of shortness of breath, abdominal and ankle swelling.

Pericardial Effusion

chytrolin94: Hello, can pericardial effusion cause pericarditis and fainting?

Allan Klein, MD: Usually pericarditis can cause pericardial effusion. If the effusion is very large and compresses the heart, people could get short of breath and have low blood pressure and faint.

Activity, Exercise and Pericarditis

Nurse2: Regarding recurrent pericarditis presently on triple therapy and symptomatic. If this person is experiencing fatigue and if her heart rate increases with any activity whatsoever (despite beta-blockers), is it safe for her to attempt to take walks or is this going to make her symptomology worse? She is using a Fitbit to monitor her heart rate and needs to stop very often to keep it less than 100, but is this okay to do? Is this normal in the context of recurrent pericarditis while attempting to taper from triple therapy?

Allan Klein, MD: She can continue to walk and see if she has any symptoms. We are conducting a study on the effect of exercise and worsening of pericarditis. There is not a lot of data concerning this topic. Usually we suggest a heart rate less than 100 bpm.

Ollie12: I have had auto-inflammatory chronic pericarditis for six years and am on colchicine, methotrexate and hydroxychloroquine. I started anakinra six months ago with improvement, although I still have flares if I push exercise. My CRP is normal. How much symptomatic improvement should there be on anakinra to justify its continuation?

Allan Klein, MD: I would not recommend pushing exercise on active therapy for pericarditis. I am not sure whether the anakinra is not working or the exercise is aggravating it - or both.

Justbreathe: If a patient is placed on an activity restriction, when is the restriction lifted?

Allan Klein, MD: When they finish the medical therapy. This could take quite some time. We do encourage walking activity. No couch potatoes!

Ollie12: I have had auto-inflammatory chronic pericarditis since 2012.My exercise tolerance has been limited to 2-3 functional hours /day and about 200 yards at a time. I started anakinra 6 months ago with improvement. How quickly should you increase exercise and how long would you expect it to be before regaining normal exercise tolerance. Thank you.

Allan Klein, MD: I would not recommend active exercise when on anakinra - only when off of it. This is defined as heart rate greater than 100 bpm.

Justbreathe: If someone is unable to travel one flight of stairs without exceeding their activity restriction of hr <100. Is that a concern? Does that seem excessive or concerning?

Allan Klein, MD: Yes this is concerning. You should be evaluated.

Miscellaneous Pericarditis Questions

Nurse2: How does one pursue genetic testing if you indicate there's a genetic component to pericarditis.

Allan Klein, MD: We are studying the aspect of genetics for pericarditis but the results may not come out for several years. We hypothesize there can be a genetic pre-disposition.

ssbronx: My 42-year-old husband, who is in perfect health, contracted pericarditis in the spring. He never had more than 2-3 cm of fluid and took colchicine and ibuprofen for about six weeks. He had intense bouts of a-fib during the illness which was the worst part. He's just now weaning himself off of metoprolol and is back to health. What could have caused this and do you think it could come back? Thanks!

Allan Klein, MD: Most likely it was viral and 30% come back.

Nurse2: 1) does pericarditis weaken your heart muscle over time and how does it affect overall function? 2) What changes would you see if this happens with respect to symptoms and testing?

Allan Klein, MD: There is a condition called peri-myocarditis which involves mainly the heart muscle and some pericarditis. In these cases you may need to treat the weakened heart muscle with beta blockers and ace inhibitors. There is a condition called constrictive pericarditis which can have the calcified pericardium grow into the muscle causing tethering of the muscle.

TinaRae: What are your thoughts about pushing for immunization for Coxsackie virus?

Allan Klein, MD: I am not sure if there is a vaccination for the coxsackie virus.

TinaRae: Can you add a psychiatrist or counseling to your Pericarditis Team?  Can your team help us with the psychological aspects of this disease? I am afraid your team is very much alone in understanding Pericarditis in itself and the psychological impact associated with this condition. I am concerned if I need to start Prednisone, it will amplify my current symptoms of depression and anxiety amplified by this condition and the lack of medical professional competency related to Pericarditis. I would like to have the Genesight test completed to prepare for the long game and for the possible addition of prednisone. Is this something that can be added to the treatment plan for Pericarditis through the Pericarditis Clinic? It would be a great help to have that services available under the same roof.

Allan Klein, MD: That is a very good idea. That would have to be organized in the future.

TinaRae: First and fore most I would like to take this opportunity I have been waiting for and express my sincere gratitude. Your online videos helped me when I was at a very vulnerable time in my life. Extreme ongoing cardiac chest pain can create a very distressing life experience. Your online education helped me through this when no one else could. Please continue to educate professionals and give full access to those of us who have nowhere to turn. Thank you.

Allan Klein, MD: Appreciate your comments. Also you should know that we are performing clinical trials involving a biologic called rilonacept in patients with idiopathic recurrent pericarditis or post cardiac injury syndrome.

Nurse2: Is there an outreach support group for patients with complicated pericarditis that do not live in Cleveland, or is there a way to network with others sharing similar difficulties?

Allan Klein, MD: Please see this Facebook group - A foundation for pericarditis would be a great idea to be organized.

Elinore: Do all Cleveland Heart Centers have Pericardial Centers?

Allan Klein, MD: Cleveland Clinic Main Campus in Cleveland, OH - we have a team of specialists in our Pericardial Center.

Nurse2: 1) profound fatigue and a heart rate increase with even the slightest exertion is very disabling in a person with chronic recurrent disease. What would be the concern and what can be done 2)Would you recommend a rheumatologist at Cleveland clinic to compliment the care your team provides in evaluation?

Allan Klein, MD: Definitely. Planning ahead is very important.

Reviewed: 11/18

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