The pericardium is a thin, two-layered, fluid-filled sac that covers the outer surface of the heart. It provides lubrication for the heart, shields the heart from infection and malignancy, and contains the heart in the chest wall. It also keeps the heart from over-expanding when blood volume increases, which keeps the heart functioning efficiently.
What is pericarditis?
Pericarditis is an inflammation of the pericardium. Pericarditis is usually acute – it develops suddenly and may last up to several months. The condition usually clears up after 3 months, but sometimes attacks can come and go for years. When you have pericarditis, the membrane around your heart is red and swollen, like the skin around a cut that becomes inflamed. Sometimes there is extra fluid in the space between the pericardial layers, which is called pericardial effusion. Pericarditis can affect anyone, but it is most common in men aged 16 to 65.
Symptoms and Causes
What are the symptoms of pericarditis?
Pericarditis can cause chest pain that:
- Is sharp and stabbing (caused by the heart rubbing against the pericardium)
- May get worse when you cough, swallow, take deep breaths or lie flat
- Feels better when you sit up and lean forward
You also may feel the need to bend over or hold your chest to breathe more comfortably.
Other symptoms include:
- Pain in your back, neck or left shoulder Trouble breathing when you lie down
- A dry cough
- Anxiety or fatigue
Pericarditis can cause swelling in your feet, legs and ankles. This swelling may be a symptom of constrictive pericarditis. This is a serious type of pericarditis where the pericardium gets hard and/or thick. When this happens, the heart muscle can’t expand, and it keeps your heart from working like it should. Your heart can become compressed, which causes blood to back up into your lungs, abdomen and legs, and cause swelling. You can also develop an abnormal heart rhythm.
If you have symptoms of constrictive pericarditis, including shortness of breath, swelling of the legs and feet, water retention, heart palpitations, and severe swelling of the abdomen, call your cardiologist to schedule an evaluation.
Pericardial effusion and cardiac tamponade
When there is a fluid build-up in the space between the pericardium, it can cause a condition called pericardial effusion. If the fluid builds up quickly, it can cause cardiac tamponade. This is a sudden build-up of fluid in between the layers of the pericardium that keeps your heart from working like it should and can cause your blood pressure to drop. Cardiac tamponade is life-threatening and requires immediate drainage of the fluid.
If you have any symptoms of acute pericarditis, call your doctor right away. If you feel your symptoms are a medical emergency, call 911 right away to get treatment at the nearest hospital.
What causes pericarditis?
There are many causes of pericarditis:
- Viral pericarditis is caused by a complication of a viral infection, most often a gastrointestinal virus.
- Bacterial pericarditis is caused by a bacterial infection, including tuberculosis.
- Fungal pericarditis is caused by a fungal infection.
- Parasitic pericarditis is caused by an infection from a parasite.
- Some autoimmune diseases, such as lupus, rheumatoid arthritis and scleroderma can cause pericarditis. Other causes of pericarditis include injury to the chest, such as after a car accident (traumatic pericarditis), other health problems such as kidney failure (uremic pericarditis), tumors, genetic diseases such as Familial Mediterranean Fever (FMF), or rarely, medications that suppress the immune system.
Your risk of pericarditis is higher after a heart attack, heart surgery (postpericardiotomy syndrome), radiation therapy or a percutaneous treatment, such as cardiac catheterization or radiofrequency ablation (RFA). In these cases, it is likely that the inflammation of the pericardium is an error in the body’s response to the procedure or condition. It can sometimes take several weeks for symptoms of pericarditis to develop after bypass surgery.
Many times, the cause of pericarditis is unknown. This is called idiopathic pericarditis.
About 15-30% of patients with pericarditis have repeat episodes of pericarditis that come and go for many years.
Diagnosis and Tests
How is pericarditis diagnosed?
Sharp pain in the chest and back of the shoulders and difficulty breathing are 2 major clues that you may have pericarditis rather than a heart attack. Your doctor will talk to you about your symptoms and medical history, such as whether you have recently been sick and review your history of heart conditions, surgery and other health problems that could put you at a higher risk of pericarditis.
Your doctor will listen to your heart. Pericarditis can cause a rubbing or creaking sound, caused by the rubbing of the inflamed lining of the pericardium. This is called the “pericardial rub” and is best heard when you lean forward, hold your breath and breathe out. Depending on how bad the inflammation is, your doctor may also hear crackles in your lungs, which are signs of fluid in the space around the lungs or extra fluid in the pericardium.
Cleveland Clinic imaging specialists in the Center for the Diagnosis and Treatment of Pericardial Diseases often use a variety of ways to check for pericarditis and any complications, such as pericardial effusion or constrictive pericarditis. You may need one or more tests, such as:
- Chest X-ray to see the size of your heart and any fluid in your lungs.
- Electrocardiogram (ECG or EKG) to look for changes in your heart rhythm. In about half of all patients with pericarditis, the heart rhythm goes through a sequence of four distinct patterns. Some patients do not have any changes, and if they do, they may be temporary.
- Echocardiogram (echo) to see how well your heart is working and check for fluid or pericardial effusion around the heart. An echo will show the classic signs of constrictive pericarditis, including a stiff or thick pericardium that constricts the heart’s normal movement.
- Cardiac MRI to check for extra fluid in the pericardium, pericardial inflammation or thickening, or compression of the heart. A contrast agent called gadolinium is used during this highly specialized test.
- CT scan to look for calcium in the pericardium, fluid, inflammation, tumors and disease of the areas around the heart. Iodine dye is used during the test to get more information about the inflammation. This is an important test for patients who may need surgery for constrictive pericarditis.
- Cardiac catheterization to get information about the filling pressures in the heart. This is used to confirm a diagnosis of constrictive pericarditis.
- Blood tests can be used to make sure you are not having a heart attack, to see how well your heart is working, test the fluid in the pericardium and help find the cause of pericarditis. If you have pericarditis, it is common for your sedimentation rate (ESR)and ultra sensitive C reactive protein levels (markers of inflammation) to be higher than normal. You may need other tests to check for autoimmune diseases like lupus and rheumatoid arthritis.
Management and Treatment
What treatments are available for patients with pericarditis?
Treatment for acute pericarditis may include medication for pain and inflammation, such as ibuprofen and aspirin. Depending on the cause of your pericarditis, you may need an antibiotic or antifungal medication.
If your symptoms are severe, last longer than 2 weeks, or clear up and then return, your doctor may also prescribe an anti-inflammatory drug called colchicine. Colchicine can help control the inflammation and prevent pericarditis from returning weeks or even months later.
If you need to take large doses of ibuprofen, your doctor may prescribe medications to ease gastrointestinal symptoms. If you take large doses of nonsteroidal anti-inflammatory drugs (NSAIDs), you will need frequent follow-up appointments to look for changes in your kidney and liver function.
If you have chronic or recurrent pericarditis, you may need to take NSAIDs or colchicine for several years, even if you feel well.A diuretic (“water pill”) usually helps get rid of the extra fluid caused by constrictive pericarditis. If you develop a heart rhythm problem, your doctor will talk to you about treatment.
Your doctor may also talk to you about treatment with steroids or other medications, such as azathioprine, IV human immunoglobulins, anakinra.
Most times, medications are the only treatment needed for patients with pericarditis. But, if fluid builds up in the pericardium and compresses the heart, you may need a procedure called pericardiocentesis. A long, thin tube called a catheter is used to drain the extra fluid. The catheter and a needle are guided to the pericardium with the use of echocardiography. If the fluid cannot be drained with the needle, a surgical procedure called a pericardial window is performed.
If you have constrictive pericarditis, you may need to have some of your pericardium removed. The surgery is called a pericardiectomy.
Surgery is not usually used as treatment for patients with recurrent pericarditis, but your doctor may talk to you about it if other treatments aren’t successful.
Outlook / Prognosis
Will pericarditis affect me in the long-term?
After you recover from pericarditis, you should be able to return to your normal activities without any reason for concern. Your doctor will talk to you about what to expect.
How do I find a doctor who can diagnose my condition and provide treatment?
The multidisciplinary team of experts in the Center for the Diagnosis and Treatment of Pericardial Diseases includes cardiologists, cardiac surgeons, nurses and other specialists, such as rheumatologists and infectious disease physicians. We provide:
- A thorough evaluation of patients using state-of-the-art diagnostic testing
- Multi-disciplinary approach to comprehensive care for patients with pericardial diseases
- Ongoing research and education to provide patients with high-quality and innovative therapies
For more information
If you need more information or would like to make an appointment with a specialist, contact us, chat online with a nurse or call the Miller Family Heart, Vascular & Thoracic Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
Glossary of Pericarditis Terms
- Acute pericarditis: Inflammation of the pericardium that develops suddenly and is accompanied by the sudden onset of symptoms.
- Cardiac tamponade: A severe compression of the heart that impairs its ability to function. Cardiac tamponade is a medical emergency that requires prompt diagnosis and treatment. Chronic pericarditis:Inflammation of the pericardium that lasts for three months or longer after the initial acute attack.
- Constrictive pericarditis: A severe form of pericarditis in which the inflamed layers of the pericardium stiffen, develop scar tissue, thicken and stick together. Constrictive pericarditis interferes with the normal function of the heart.
- Infectious pericarditis: Pericarditis that develops as the result of a viral, bacterial, fungal or parasitic infection.
- Idiopathic pericarditis: Pericarditis that does not have a known cause.
- Pericardium: The thin, two-layered, fluid-filled sac that covers the outer surface of the heart.
- Pericardial effusion: Excess fluid build-up in the pericardium.
- Pericardial window: A minimally invasive surgical procedure performed to drain fluid that has accumulated in the pericardium. This surgical procedure involves a small chest incision through which an opening is made in the pericardium.
- Pericardiectomy: Surgical treatment of pericarditis that involves the removal of a portion of the pericardium.
- Pericardiocentesis: A procedure performed to drain excess fluid from the pericardium with a catheter.
- Traumatic pericarditis: Pericarditis that develops as the result of injury to the chest, such as after a car accident.
- Uremic pericarditis: Pericarditis that develops as the result of kidney failure.