Allan Klein, MD
Allan Klein, MD

Douglas Johnston, MD
Douglas Johnston, MD

Friday, August 14, 2015 - 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. Dr. Klein and Dr. Johnston answer your questions about pericarditis and other pericardial conditions.

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Pericarditis Symptoms

Hank26: I have had pain with breathing and think I have pericarditis based on stuff I read on the internet. I do not have insurance. Anything I can start to take over the counter to see if it goes away?

Allan_Klein,_MD: If you think you have pericarditis and you have no insurance, you could start low dose ibuprofen two times a day with stomach medicine (like pepcid) to help with stomach issues. Then you will need to see a cardiologist. Most hospitals will have help for people like you with resources for signing up for insurance.

VanessaC: Question about the fatigue aspect of Pericarditis - It's the crushing fatigue that really affects my life the most. After relatively minor exertion, I will be exhausted for the following couple of days (more if the exertion is bigger) coupled with a flare-up of symptoms - burning chest and lungs, faster heart rate and breathing, all worse lying down. Do you have any insight into physiologically what this is? I don't have constriction so can it still be due to reduced cardiac output? Does the lung element affect efficient respiration? Is it down to deconditioning, so that I get a smaller version of what a fit person would get two days after a marathon? It's the fatigue that renders me unable to work, socialize or exercise. I have attended a chronic fatigue syndrome clinic (who said I don't have CFS) and they recommend graded exercise - but I don't feel I can exercise during a flare. I feel like I’m stuck in a vicious circle of being unfit and unable to exercise, but too unfit to fight it.

Allan_Klein,_MD: The fatigue could be part of the whole chronic illness of recurrent pericarditis with frequent relapses and multiple medicines. In general as mentioned, we do not encourage fast heart rates during active or acute pericarditis. For your difficult case, you should see a center of excellence in pericarditis. We are happy to see you here.

bgm: I have been diagnosed with Pericarditis a few weeks ago and I'm just wondering, is it normal to feel pain in your upper right chest and on your left upper side as well? These pains are off and on throughout the day and I have been taking Ibuprofen 800 twice a day for 2-3 weeks and just started taking Colchicine this past Tuesday (8-11-15) but still get pain in my right upper middle chest area and on the left by my close to my armpit. Is there anything I can do to avoid being in pain and how long does should it take before I start to feel better? I also tend to feel as if I get palpitations at times. Is this normal? One of my biggest fears is that this will last longer than the three month time frame I read about. I am unsure if I have had it for a while so I do not if I should be worried?

Allan_Klein,_MD: The acute pericarditis could last longer than three months. It is important to stay on the medicines with very slow tapers to allow healing. Palpitations can be associated with the pericarditis (example atrial fibrillation).

bgm: When I get pain in my upper middle chest on my right and on my upper left side and sometimes the bottom (not the middle), it lasts close to a minute or longer. I press on certain spots and it hurts. Is this something I should feel worrisome about? Would ice help out at all? Any foods or drinks should I avoid?

Douglas_Johnston,_MD: What you are describing sounds like costochondritis, which is pain arising from the joints between the ribs and the sternum. This is a very common problem and usually goes away on its own. If it becomes more frequent or constant you should see a physician, but chest wall pain of this sort is unlikely to be serious.

bgm: Thank you for taking the time to answer questions about this. I am not sure if you saw but I asked if it's possible if Pericarditis causes headaches? If you answer this before you get to this particular question, sorry about that. I have also had Psoriasis for a number of years, would it also be a possibility that this could be one of the causes or are they not related?

Allan_Klein,_MD: Psoriasis is an autoimmune disease that can be associated with pericarditis. Headaches is not usually related to pericarditis unless it is related to one of the medicines.

pfizeron: Is pain with SOB a common feature? We notice a pattern of pain and SOB relieved by Tramadol and Ativan.

Allan_Klein,_MD: You do not mention pericarditis. Tramadol and Ativan could help you relax however, these are not anti-inflammatories used to treat pericarditis.

pfizeron: I have a patient who has been diagnosed with simple pericarditis. No complications whatsoever. However, she complains of CP and SOB after either an anxiety attack or overexertion. The CP and SOB appear to go hand in hand. We have had a number of EKG's to r/o MI. Typically her SOB score is always +1 greater than her CP score. She complains that the SOB feels like a small localized portion of her airway is "stopped up" until relieved by pain meds plus 1/2 mg of lorazepam. This has been a consistent pattern for more than three weeks now. Your thoughts...

Allan_Klein,_MD: Probably the pericarditis is recurring and has to be treated adequately. Otherwise, it will keep on recurring. We would be glad to see her.

dle1649: I had shortness of breath due to pain when inhaling and exhaustion came quickly. Also had pain in chest. Is this normal with pericarditis?

Allan_Klein,_MD: See a previous answer for criteria for pericarditis Your symptoms may not be pericarditis.

Sue B.: Can a heart patient live with pericarditis and not know it? I am a 56-year-old, woman with severe pain on the left side of my surgery. I had aortic aneurysm repaired, aortic valve replacement, porcine, and mitral valve repair which was supposed to be a replacement. Second surgery was required a month later due to a staph bone infection from another patient. Replaced my sternum and ribs with cage. Five years later came down with a cough, then agonizing pain all around surgery site. Could not sneeze, cough, burp, could not lay down, limited use of my arms because of the pain. Told at the ER I had Costochondritis, put on anti-inflammatory, but still have stabbing pain in left area of surgery and upper left breast close to shoulder, feels like something stabbing me. I run a low grade fever 99.1-101.5 every once in a while. I can't have any more surgeries due to the cage being installed. Do I just live with this? Changing bra's makes it worse.

Douglas_Johnston,_MD: The pain you describe sounds more like it is emanating from the chest wall given your history. A small percentage of patients develop chest wall pain after surgery which can mimic pericarditis or other pathology. Making a diagnosis can be difficult and often patients go through several different treatment regimens before getting it under control. A pain specialist can be a great help in these cases.

Pericarditis Diagnosis and Causes

Wirral1: If blood markers are normal and there is no pericardial rub however there is a very small effusion present combined with ongoing very periodic chest pain is pericarditis still in play?

Allan_Klein,_MD: The diagnosis of pericarditis includes four - six things: Classic chest pain with breathing; EKG changes; a new or worsening pericardial effusion; and a pericardial rub. Additional findings are inflammatory markers and MRI. It is not clear to me which of those you have and if you have been treated. This will affect your blood markers.

WarringtonUK1: If an MRI doesn't show thickening of the pericardium, can an MRI show anything else that could indicate constriction?

Douglas_Johnston,_MD: MRI is useful not only for looking at thickening but can show inflammation of the pericardium, and also is a very good tool to look at the motion of the heart muscle and the flow of blood through the heart. There are features of the shape and motion of the heart, in particular a diastolic septal bounce, conical deformity of the ventricles, and tethering, which are very suggestive of pericarditis apart from the thickness and characteristics of the pericardium itself.

Nurse2: What if patients due to AICD cannot have MRI?

Allan_Klein,_MD: You would be limited then to a good LV mechanics echo assessing pericardial effusion and physiology; biomarkers and non-contrast CT if they wanted to assess pericardial thickness.

WarringtonUK1: Please could you define how many mm thick constitutes 'thickening of the pericardium'? I have seen various thicknesses defined, from 1mm to 4mm. My cardiologist says I have no thickening, despite having symptoms of constriction and I would be interested to ask him what thickness was measured on my MRI.

Allan_Klein,_MD: Pericardial thickness can be measured by either CT or MRI. TEE (transesophageal echo) can measure pericardial thickness. The absolute cut off depends upon technique and location where the pericardium is seen. In general, greater than or equal to 3 mm would be abnormal. It also depends on the interpreter, where they put their calipers.

jud: About one month ago I had about 20 teeth extracted. Prior to the operation I was given a RX for antibiotics. I began taking the antibiotics prior to the procedure and continued taking them until the supply was exhausted. On August 7, I went to the emergency room of a local hospital. I was experiencing chest pain when I tried to take a deep breath. I was given a battery of tests. I was diagnosed as having Pericarditis. Upon release, release after about eight hours, I was instructed to take Advil to reduce the inflammation. The next day all was good. No discomfort. My question is: Could my oral infection have caused the inflammation? Also, I have type II Diabetes.

Allan_Klein,_MD: The most common cause would be a viral illness. It would be unlikely that a dental infection causes pericarditis.

Linsaynicole: The past few flare ups I have had, my blood work has come back completely normal. Is there a specific test I should recommend my rheumatologist to run? I know blood values don't always indicate a flare, but I am wondering if there is something off a normal blood panel that I am not being tested for that could help my doctors treat me.

Allan_Klein,_MD: The blood test can be normal if it has been treated adequately with medicine. Patients with pericarditis can often have other types of pains that is not pericarditis, thus there can be normal markers. Probably, you would need a combination of symptoms, signs, inflammatory markers and even imaging to sort out what is causing the pain.

Igor_2015: If a patient has IRP, with CRP levels are above 100, positive WBC, positive sed rate and significant chest pain what is recommended treatment protocol?

Allan_Klein,_MD: You should definitely be seen at a center of excellence.

Constrictive Pericarditis

Jimsdad: My dad had valve replacement three years ago and now has been diagnosed with constrictive pericarditis. Is that related? Is surgery the treatment for this type of pericarditis? He does not want to go through surgery again.

Douglas_Johnston,_MD: In some patients, inflammation after surgery is the cause of pericarditis. Making a diagnosis of pericardial constriction in these cases is more difficult than in a patient who has not had surgery. The first thing would be to be sure this is the diagnosis, and whether the pericarditis is related to active inflammation or scarring. If it is related to inflammation there are often options for medical treatment.

jcollin1: I have just been diagnosed with constrictive pericarditis with all the following tests; cardiac catheterization, echocardiogram (multiple), blood work, and finally MRI. I am in perfect health except for this constriction. My choice is to go to Boston (1.5 hrs. away) or Cleveland (11 hrs away). My question is: after hospital surgery recovery period which is usually five to seven days, do I return to New Hampshire and my local cardiologist sees me for follow up, or do I have to return to Cleveland? Will I be able to return to New Hampshire for six-eight week recovery period?

Allan_Klein,_MD: I would definitely recommend a large center with a Pericardial Clinic to evaluate if this is constriction and if there is an inflammatory component. Occasionally this can be treated with anti-inflammatories if it is subacute. We would recommend Dr. Johnston at Cleveland Clinic who does 40 - 50 per year.

Wirral1: Can the pericardium still be constricted if thickening isn't shown on MRI or no calcification is shown on CT.

Allan_Klein,_MD: Yes - the pericardium can be constricted without pericardial thickening or calcification.

Wirral1: Can the heart still be constricted if there's no evidence of thickening and no evidence of calcium. If constriction IS still possible, what other clinical signs should the consultant be looking for to confirm constriction? Background info - a history of acute pericarditis (treated with NSAIDs/colchicine). Also an echo has shown septal bounce and a small effusion. There is also very poor tolerance to exertion, with a high heart rate (up to 180 bpm) on exertion and extreme shortness of breath. A CT pulmonary angiogram has been done, as well as two cardiac MRIs (one has shown the possibility of 'reversible ischemia', the other something 'subtle' (unknown to the patient)), a CT cardiac calcium scoring and a cardiac catheterization (coronary angiogram). The symptoms point to constriction but there are few defining signs on imaging.

Douglas_Johnston,_MD: Constriction can occur in the absence of significant thickening and calcium, though thickening is common in severe constriction. An MRI is a good study to look at constriction, though at Cleveland Clinic we employ the combination of ECHO, MRI, and a combined right and left heart catheterization to be as sure as possible of the diagnosis. Classically patients with constriction complain most about fatigue and swelling of the legs. Shortness of breath as the main symptom is unusual and should prompt a close look at other causes. With the suggestion of reversible ischemia, I would suggest that you will need a catheterization to look at the coronaries. A right heart cath at the same time can help to rule in or out constriction.

Ricej07: My husband has been diagnosed with Constrictive Pericarditis at your clinic and will need to have the surgery at some point. What is the benefit to waiting to have the surgery? Currently he feels good and continues to exercise and be active. Does waiting for surgery have any negative effect on the heart's long term function?

Douglas_Johnston,_MD: The decision about timing of surgery in constriction is not always easy. In general we want to operate before patients become deconditioned or have severe symptoms, but when they do have severe constriction as demonstrated by the ECHO, MRI, and right and left heart cath. Some people go many years with mild or moderate constriction and few symptoms, and we do not want to subject patients to the risk of surgery, even though this risk is relatively low for otherwise healthy patients, if surgery is not likely to make them feel significantly better. The decision for timing should be made in concert with the surgeon, cardiologist and patient looking at all of these data.

Ricej07: My husband's last tests (MRI, chest x-ray, ECHO, stress test, blood work, etc.) were done in January at your clinic. He is currently having more tests done as a follow-up. We opted to do them here (Carlisle, PA) with his local cardiologist and have them sent. Do you prefer to have tests done at your facility or will you be able to use what we send to you?

Douglas_Johnston,_MD: We often use tests from out of state when it is more convenient for patients. As long as there is close communication with the patient and outside physician we can make this work. We follow patients from around the US and several other countries and will work with patients to be sure they can be followed closely wherever they are.

Recurrent Pericarditis

beavecrat: How can you determine if scarring of the pericardium has occurred due to recurrent pericarditis, and are there symptoms that would indicate scarring?

Allan_Klein,_MD: Recurrent pericarditis can be associated with inflammation of the pericardial sac; often detected by cardiac MRI. Over time, the inflammation will disappear and scarring will occur. This shows up as increased pericardial thickness.

Nurse2: How do you differentiate constrictive from chronic pericarditis?

Allan_Klein,_MD: Usually you want to differentiate constrictive pericarditis from restrictive cardiomyopathy. If the pericarditis lasts more than three months, this can be considered chronic. Chronic pericarditis can include recurrent as well as constriction.

tammimiami: I have had pericarditis that occurs about once a year or so for several years. This year I have had it three times. They put me on prednisone and colchicine. The last time also had a pericardial effusion and it seems to be lasting a long time - does this mean it is getting worse or something is changing? What do you recommend? Will it keep getting worse and more frequent?

Allan_Klein,_MD: It seems to me that the medicines are being tapered too quickly. That is not enough time to heal the pericarditis and pericardial effusion.

dle1649: If you have pericarditis for 1st time at age 70, what are the odds of reoccurrence?

Allan_Klein,_MD: There is still a good 20-30% chance for recurrence; no matter what the age is. It also depends on the cause of the pericarditis.

BETHELMOM: Thank you for hosting this again - it is always very informative. My daughter was hospitalized 4 1/2 yrs. ago with acute pericarditis. Unfortunately they put her on prednisone and she to this day is having a very hard time being weaned off of the steroids. My questions today are:

  1. Can the time or day or seasons of the year and/or certain foods trigger flare up?
  2. It has been recommended she take Kineret daily shots (unfortunately her insurance refuses to pay for this expensive treatment). There is not much information out there regarding this treatment. Do you have any data or do you recommend?
  3. Do you have any insight or thoughts on getting someone weaned of prednisone (she seems to have "flare ups" when she decreases to 5mg). The doctors having her take Aleve to help alleviate the pain but it gets to a point where that does not help with the heaviness, pain in chest, neck, back etc.).

Thank you.

Allan_Klein,_MD: For your daughter's difficult case, she should see a specialist here at Cleveland Clinic. For the tapering often you are on triple anti-inflammatory therapy with very slow tapering. For the anakinra, would recommend that your rheumatologist, cardiologist and you write to the insurance company and their managers to fight for the coverage. I have a patient in N. Carolina who successfully obtained anakinra with this pressure.

BETHELMOM: You mention my daughter's rheumatologist and cardiologist fight w/insurance company for anakinra. Is this the same as kineret? (we have already fought w/insurance for kineret and they still refused).

Douglas_Johnston,_MD: Kineret is the trade name.

Idiopathic Pericarditis

Margareta: I am 60 years old, diabetic, cancer survivor and have been diagnosed with idiopathic pericarditis, two and a half years ago. I don't have lupus and I have never had fluid. Whenever I get off steroids or on a low dosage, after two - five weeks, I get another episode and have to go back on a higher dosage. At the beginning I was on Ibuprofen, then Prednisone and Colchicine for more than one year, without any success. Currently, I am treated by a rheumatologist and take 2mg of Methylprednisolone and 400mg of Hydroxychloroquine. Is there anything else I can do?

Douglas_Johnston,_MD: In some cases patients like you are treated with surgery. It would be important to be sure that the tapering of steroids is done very slowly and in combination with colchicine. Dr. Klein has been successful tapering patients off of medication when they have had trouble before. If tapering off steroids is not possible surgery can be considered.

RaLogsdon: In cases of idiopathic pericarditis, what percentage of patients actually recover to a point where there are no flare-ups for at least a year? Should someone recovering from pericarditis use caution when seeing the dentist or having surgery?

Allan_Klein,_MD: 70% of patients with acute pericarditis have no recurrences. However, the process has to be well treated to prevent the recurrences. Very important to avoid steroids with fast tapering early on. If the pericarditis is active and the medicines have to be interrupted due to surgery, this would not be a good idea.

Pericarditis and Rheumatology Related Questions

Carcanta: I have recurrent pericarditis and have been to rheumatologist who said I also have lupus. Dose that change the way I am treated or how to treat me? I keep getting the pericarditis back with symptoms.

Allan_Klein,_MD: Lupus often causes pericarditis. The key thing is to control the lupus with various medicines. The general treatment of the pericarditis is the same in addition to the lupus medications.

VanessaC: A question about the lung aspect of pericarditis - My pericarditis seems to affect my heart and my lungs both together, and independently. My rheumatologist said pericarditis is like auto-immune serositis in that it affects the serous tissues of the thoracic cavity, pericardium, pleura and peritoneum. I can have sore, burning lungs and no heart pain, and an achy burning heart and happy lungs. My lungs flare up after physical exertion. The lung burning is like I used to get after intense prolonged exercise, such as long distance running. I now get that after vastly less exertion and it can take a day or more to pass. This lung burn happens regardless of pain killers. I got it this week after standing for an hour, and i got tired and out of breath! I used to cycle 20 miles a weekend. What is the 'burn'? Is this due to physical deconditioning? Is it lactic acid build up? Are the lower alveoli underused, and hurt when i increase my lung capacity? Will graded exercise therapy help that?

Allan_Klein,_MD: IF you have a serositis, especially pericarditis, affecting the pericardium, exercise with heart rate above 100 bpm is probably not the best thing to heal the pericarditis. Usually when you treat the pericarditis, the pleuritis improves as well.

ladydej: Hello I am a 44-year-old female that was dx on May 25 w/pericarditis, and a small pericardial effusion. Initially my treatment was scattered because my rheumy was on leave and no one wanted to accept care because of my CTD. Since my rheumy is trying to taper me off of 60 mg prednisone, but each time the pain returns. I am on 0.6 colchicine, 200 Imuran (undifferentiated connective tissue disease), and 180 Cardizem. Initially my treatment was various tapered doses of prednisone and anti-inflammatories. I am currently unable to return to work because each time I think everything is ok the crippling chest pain returns, I try to stay active but that worsens it, the effusion has resolved but I am confused because the symptoms seem worse at times (negative myocarditis), my labs are improving other than the prednisone side effects. However, why am I still experiencing pain that is now waking me up at night? What is the prognosis of Pericarditis? Will it ever go away? Please help!

Allan_Klein,_MD: The connective tissue disease associated pericarditis is driven by the rheumatologic condition. Therefore, adequate treatment of the CTD is important. At Cleveland Clinic we often use imaging and biomarkers to guide the therapy. You probably need the cardiologist and the rheumatologist to work together to decide how many drugs and the speed of tapering.

VanessaC: Can viral pericarditis turn autoimmune (Even if all screens come in negative for Lupus, RS and FMF) and then be successfully treated with Imuran or kinaret?

Allan_Klein,_MD: The viral pericarditis is most likely autoinflammatory vs. autoimmune, like lupus. They are treated in a similar way.

Pericardial Effusion

Marcus76: My dad had bypass surgery and returned home end of July. since that time he has gone back twice for pericardial effusions requiring draining. Will this continue? Why does it keep occurring?

Douglas_Johnston,_MD: For reasons that are not well understood, some patients have prolonged inflammation in the chest after heart or lung surgery, and develop recurrent fluid collections. In some cases this is made worse by blood thinner medications that patients may require. Drugs like colchicine and other anti-inflammatories can help in reducing the inflammation and speed the healing process. In your father's case it is still early after surgery, and these problems tend to calm down on their own within the first six - eight weeks.

ohiopeggy: What is the difference between pericarditis and pericardial effusion? Might I have both?

Douglas_Johnston,_MD: Pericarditis is inflammation of the pericardium. It can occur with or without effusion. Likewise an effusion, which is a collection of fluid around the heart, can occur with pericardium that appears relatively normal and with no or minimal pericarditis.

Pericardial Mass and Pericardial Cyst

GraciefromWA: I have been diagnosed with a benign pericardial mass but have also had recurrent bouts of pericarditis. Is it related? Would they remove the mass? If so - can that be done minimally invasive?

Douglas_Johnston,_MD: There are a number of masses which can affect the pericardium. Some, like pericardial cysts, can be associated with pain and feel like pericarditis. While most of these are benign it is not possible to tell definitively without taking the mass out. That can often be done minimally invasively.

ThomasB: Have been diagnosed with pericardial cyst. Have chest pain and shortness of breath. Have been given pain meds by my primary doctor who told me I will need to see a specialist. Tell me what the treatment is and what type of cardiologist I need to see.

Douglas_Johnston,_MD: We believe most pericardial cysts, if they become symptomatic, should be removed. This can be done by a cardiac surgeon or a thoracic surgeon, and can usually be done with a very small incision.

Pericarditis – Medical Management

Linsaynicole: How long is it safe to be on colchicine? Have any long term studies been done? I take pepcid along with advil when I'm having a flare, but take colchicine all the time. Is there any additional medicine I should take with colchicine? Is this a medicine that is safe to be on for years and years if necessary?

Allan_Klein,_MD: Colchicine is relatively safe compared to prednisone. I would advise if the pericarditis is controlled, slow tapering from twice a day to once a day, then half and then off over several months. If it comes back, and the markers are elevated, you may have to restart low dose. The biggest side effect would be GI and hair loss; and occasionally elevated liver function tests. Pepcid would be good with the advil.

debbrier: Hi. I know you are prescribing anakinra more often these days. Curious why that over Imuran or anything since the anakinra is so very expensive?

Allan_Klein,_MD: Usually after triple anti-inflammatory therapy which includes NSAID, colchicine and prednisone, we often go to a DMARD, which includes Imuran, methotrexate, and cellcept. The next line of drugs is the biologics which includes anakinra. This drug shows a lot of promise how it counters the inflammation. There are several case series showing that this is a useful drug in controlling the pericarditis, although it is expensive and has to be approved by insurance.

txcathyc: Do cardiologist across the country deal with pericarditis a lot? They don't seem to be familiar with it lasting more than a few weeks. Mine is current and started in April. I was taking Advil and Colchicine with Pepcid. Now just transitioned to Indomethacin. Have only had a chest x-ray and echo. Have not had an MRI. Went to Rheumatologist and nothing was found out. What suggestions do you have to try next? I am 125 pounds and don't want to take Prednisone. If I have to, how would you dose it and taper?

Allan_Klein,_MD: No - you should try to find a center of excellence in pericardial disease like at Cleveland Clinic. I would recommend that if you have a difficult case, a cardiac MRI with a pericardial protocol could be done and based on the severity, a decision will be made how many drugs to give and for how long to taper. We try to avoid prednisone and reserve this for very resistant cases. A key thing is very slow tapers.

alicialk: I have been diagnosed with pericarditis and also have a liver problem so cannot take NSAIDs - what do you suggest?

Allan_Klein,_MD: It depends on what the cause of the liver disease is. You may have to lower the doses of the medicines, including NSAIDs and colchicine for liver or kidney disease.

Pericarditis and Exercise

Igor_2015: Thanks you for hosting this informative seminar. I have read a few articles describing the challenges in diagnosing and treating acute IRP. As a patient recovering from IRF, the high percentage of undiagnosed root causes, causes concern, as well as the lack of effectiveness of current treatment protocols.

1) Could you relay the state of current research into causation, and touch on if any efforts are ongoing to research pathways emanating from oral cavity infections? Endocarditis is a commonly understood complication from bacterial infection entering the bloodstream through the oral cavity, with the myriad of bacteria present in the mouth would there possibly be a pathway leading to pericarditis?
2) Rest is recommended as part of the recovery protocol. As a soccer coach, not exercising is like asking my Labrador not to try and lick everything in sight! Why does exercise exacerbate pericarditis??
Thank you!

Allan_Klein,_MD: Exercise in general, is good for the heart and well-being of the patient. However, imagine an inflamed pericardium (analogy: a sprained knee) - this takes time to heal. An increased heart rate with increased heart contractility will take the pericardium with it and aggravate the pericarditis. It is like running with a sprained knee. It takes time to heal. Usually we don't recommend a heart rate above 100 beats per minute (bpm) during the management and tapering of the medicines.

Pericarditis Integrative Medicine

BobTL: Have you heard of anyone using integrative measures such as acupuncture or massage to relieve the pain with pericarditis? Is it harmful to get a massage?

Allan_Klein,_MD: There are really no studies that have looked at this, however relaxation and less physical and mental stress, and slower heart rate could potentially help.


Wirral1: Is a pericardiectomy suitable for patients suffering only from severe pericardial pain arising from pericarditis?

Douglas_Johnston,_MD: Yes in some circumstances. We are increasingly considering earlier surgery for patients whose pain cannot be controlled or who are having side effects from medication. While surgery can be successful in these cases the decision requires very close collaboration between patient, cardiologist and surgeon and should be made at a center of excellence for pericardial disease.

davel: I was the victim of restrictive pericarditis and had a pericardiectomy to remove the thickened pericardium. With the pericardium removed is the heart more open to damage and disease over time? My heart has returned to a healthy state but I question whether the life span of the heart has been compromised by the removal of this pericardium?

Douglas_Johnston,_MD: The heart itself can do very well without a pericardium. In general, patients with normal heart function can have a very good quality of life and life expectancy when recovered from pericardiectomy. Part of it depends on the reason for the pericarditis.

VanessaC: I am a 47-yr-old woman living in the UK. I have had viral (?) pericarditis for two years now (incessant recurring?). All auto-immune screens have been clear. I have had two MRI's, two CT scans and three echoes. My effusion goes up and down and isn't huge. I have no scarring, thickening or constriction so far. I am so fatigued I can't work, socialize or even clean the house. I tried prednisolone (30mg 7 days, 25mg 3 days...) and it caused a huge flare and so much pain and breathlessness that my cardiologist pulled me off them after 10 days (My natural cortisol is high, 1212 last reading). I am now on 2 x 500mcg colchicine a day plus ibuprofen which doesn't control the pain. I am also trying acyclovir (20mg/day) from my endocrinologist to kill any lingering viruses (I had glandular fever 10 years ago) I'm having acupuncture and reiki. I am at my wits end. What should i do now? Try immune-suppressant drugs? Can viral pericarditis turn autoimmune? Do i just wait for it to go? I have no life!! HELP!!!

Douglas_Johnston,_MD: In some cases where pericarditis is recurring and does not respond to multiple medical regimens and patients continue to be symptomatic, pericardiectomy can be an answer. While most of the pericardiectomies we do are for constriction, there are an increasing number of patients having the procedure for intractable pain or intolerance to medication like steroids. This is not always a straightforward decision to make, but so far the results have been encouraging with many patients becoming symptom free and coming off their medications.

VanessaC: Thank you for the reply to my question about what treatment to try next - pericardiectomy sounds very serious - should I try auto-immune drugs first?

Douglas_Johnston,_MD: Absolutely we want to maximize medical therapy options before going to surgery. As a surgeon, I consult with one of my cardiology colleagues like Dr. Klein who is an expert in this disease process, and when there is consensus we have run out of medical options surgery is the next step.

Pericarditis – Other Questions

barbiern: What are the effects of Pulmonary Hypertension and Amiodarone Pulmonary Toxicity on pericarditis and pleural effusion?

Allan_Klein,_MD: There is no direct effect however, there are some medicines (like hydralazine) that can cause pericarditis.

Nurse2: Can pulmonary hypertension be caused by pericarditis? If not pericarditis, what other causes are there, and how are they addressed. In reference to earlier question, can amiodarone cause PHTN?

Allan_Klein,_MD: Pulmonary hypertension is not caused by pericarditis. There are two types of pulmonary hypertension: Pulmonary venous and pulmonary arterial. Amiodarone toxicity can affect the lungs and that can cause increased pulmonary pressures over time.

azer50: Can stress aggravate pericarditis?

Allan_Klein,_MD: Mental or physical stress can aggravate it including going for a run, a bike ride, studying for a test, hosting a party, pushing luggage in airport, or shoveling snow or coal.

Linsaynicole: Hi, I am wondering if any research has been done concerning pericarditis and women's hormones. I definitely notice an increase in symptoms close to my cycle and have heard from many other women that they have experienced the same. I am wondering if there is a medicine (maybe birth control pills?) that could control the hormone that is causing these symptoms. Is a hysterectomy the answer? Does it just have to do with the fluid retention that is a normal part of women's cycle? Thank you!

Allan_Klein,_MD: I have not seen much work on this topic. However, fluid retention could be an explanation.

Linsaynicole: How long can viral pericarditis last? I have had six episodes over the last two years and been tested for tons of different diseases, all of which came back negative. Can a "virus" last this long or does something else have to be a factor? Have any antibiotics been shown to help if it is viral? Thank you!!

Allan_Klein,_MD: The virus is one cause of pericarditis. It often damages the sac and sets up a cycle of recurrent episodes. It is important to treat the pericarditis adequately to prevent recurrence.

Linsaynicole: Has there been any research about pregnancy and pericarditis? I had a smooth pregnancy, but a hard labor and started having pericarditis symptoms soon after I started my cycle after having my child. My husband and I would really like to have another child in the next year or so, but I am so scared about the repercussions of pregnancy on my heart. I have had five episodes in the last two years. Also, if I do get pregnant, what medicines can I take during a flare up? Right now I take advil and colchicine and I know both of those aren't allowed during pregnancy. Thank you!

Allan_Klein,_MD: Pregnancy and pericarditis are not well studied. There is a limitation of what can be used during a flare-up during pregnancy. This is best managed with a high risk OB and a cardiologist. We would be happy to see you here.

VanessaC: Do you have active connections with any cardiologists or heart centers in the UK? Do you know of any that specialize in pericarditis?

Allan_Klein,_MD: Unfortunately, we do not know any in the UK - but have a recommendation in Italy with a Dr. Imazio. Or we would be happy to see you at Cleveland Clinic. We have an International Global Patient Service office.

Nurse2: Do you welcome collaboration with primary care docs and cardiologists out of state? How can this be facilitated?

Douglas_Johnston,_MD: Yes absolutely. In many of our patients, the process of diagnosis and decision for therapy cannot be reasonably completed in one visit. For patients not local to Cleveland, we collaborate with primary care physicians and cardiologists to coordinate the longitudinal care of these often complex patients.

Reviewed: 08/15

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