Pericarditis

What is pericarditis?

Pericarditis is an inflammation of the pericardium, the thin, two-layered, fluid-filled sac that covers the outer surface of your heart. Pericarditis usually develops suddenly and may last from weeks up to several months. The condition usually clears up after three months, but sometimes attacks can come and go for years. Sometimes there is extra fluid in the space between the pericardial layers, which is called pericardial effusion.

Types of pericarditis

• Acute pericarditis: Inflammation of the pericardium that develops suddenly along with the sudden onset of symptoms.
• 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 your heart’s normal function. This usually happens after multiple episodes of acute pericarditis over time.
• Infectious pericarditis: develops as the result of a viral, bacterial, fungal or parasitic infection.
• Idiopathic pericarditis: Pericarditis that doesn’t have a known cause.
• Traumatic pericarditis: develops as the result of an injury to the chest, such as after a car accident.
• Uremic pericarditis: develops as the result of kidney failure.
• Malignant pericarditis: develops as result of a cancer growing in your body.

Myocarditis vs. pericarditis

Both of these are types of inflammation in your heart, but they’re in different places. Myocarditis is in your heart muscle. Pericarditis happens in your pericardium (the lining around your heart). Most often, a virus causes myocarditis and pericarditis. Both can give you chest pain, but with pericarditis, your chest pain should feel better when you sit up and lean forward. With myocarditis, you’ll usually feel tired and weak.

Who does pericarditis affect?

Pericarditis can affect anyone, but it’s most common in men and people assigned male at birth who are between the ages of 16 and 65. An estimated 28 people per 100,000 get pericarditis each year.

How does pericarditis affect my body?

When you have pericarditis, the membrane around your heart is red and swollen, like the skin around a cut that becomes inflamed. The pericardium is a thin, two-layered, fluid-filled sac that covers the outer surface of your heart. It provides lubrication for your heart, shields it from infection and malignancy, and contains your heart in your chest wall. It also keeps your heart from overexpanding when blood volume increases, which keeps your heart functioning efficiently.

What are the symptoms of pericarditis?

Pericarditis symptoms include chest pain that:

• Is sharp and stabbing (This happens when your heart rubs against your 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 pericarditis symptoms include:

• Pain in your back, neck or left shoulder.
• Trouble breathing when you lie down.
• A dry cough.
• Palpitations (feeling like your heart is racing or beating irregularly).
• Anxiety or fatigue.
• Fever.
• Swelling of your legs, feet and ankles in severe cases.

Swelling in your feet, legs and ankles or shortness of breath every time you exert yourself may be a symptom of constrictive pericarditis. This is a severe type of pericarditis where the pericardium gets hard and/or thick. When this happens, the heart muscle can’t expand, which keeps your heart from working as it should. Your heart can become compressed, which makes blood back up into your lungs, abdomen and legs, leading to swelling and causing symptoms of congestive heart failure. You can also develop an abnormal heart rhythm.

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?

In up to 90% of cases, the cause of pericarditis is unknown. This is called idiopathic pericarditis.

There are many causes of pericarditis:

• A complication of a viral infection, most often a gastrointestinal virus, causes viral pericarditis.
• A bacterial infection, including tuberculosis, causes bacterial pericarditis.
• A fungal infection causes fungal pericarditis.
• An infection from a parasite causes parasitic pericarditis.
• Some autoimmune diseases, such as lupus, rheumatoid arthritis and scleroderma, can cause pericarditis.
• Injury to the chest, such as after a car accident, causes traumatic pericarditis.
• Kidney failure causes uremic pericarditis.
• Tumors like lymphoma causes malignant pericarditis.
• Genetic diseases such as Familial Mediterranean Fever (FMF).
• Medications that suppress the immune system (This is rare).

Your risk of pericarditis is higher after:

• A heart attack.
• Open heart surgery (postpericardiotomy syndrome).
• Radiation therapy.
• Percutaneous treatment, such as cardiac catheterization or radiofrequency ablation (RFA).

In these cases, it’s 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. Talk to your surgeon if you’re concerned about this.

How is pericarditis diagnosed?

Sharp pain in your chest and back of the shoulders that feel better when you sit up and lean forward, and chest pain with breathing are two major clues that you may have pericarditis and not a heart attack. Your healthcare provider will talk to you about your symptoms and medical history (such as whether you’ve 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 provider will listen to your heart. The rubbing of your pericardium’s inflamed lining causes a rubbing or creaking sound called the “pericardial rub." They’ll be able to hear it best when you lean forward, hold your breath and breathe out. Depending on how bad the inflammation is, your provider may also hear crackles in your lungs, which are signs of fluid in the space around your lungs or extra fluid in your pericardium.

What tests will be done to diagnose pericarditis?

Healthcare providers 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 people with pericarditis, providers see some characteristic changes to a normal heart rhythm. Some people don’t have any changes. If they do, they may be temporary.
• Echocardiogram (echo) to see how well your heart is working and check for fluid (a pericardial effusion) around your heart. An echo will show the classic signs of constrictive pericarditis, including a stiff or thick pericardium that constricts your heart’s normal movement.
• Cardiac MRI to check for extra fluid in your pericardium, pericardial inflammation or thickening, or compression of your heart. Your provider will give you a contrast agent called gadolinium during this highly specialized test.
• CT scan to look for calcium in the pericardium, fluid, inflammation, tumors and disease of the areas around your heart. Your provider uses iodine dye 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 your heart. This test can confirm a diagnosis of constrictive pericarditis.
• Blood tests can help your provider make sure you’re not having a heart attack, 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.

How is pericarditis treated?

Most times, people with pericarditis only need medications for pericarditis treatment, depending on the suspected cause. However, if you have a fluid buildup in your pericardium, you might need to have the fluid drained. If you have constrictive pericarditis, you may need surgery.

Medications for pericarditis

Treatment for acute pericarditis may include medication for pain and inflammation, such as ibuprofen or high-dose aspirin. Depending on the cause of your pericarditis, you may need an antibiotic or antifungal medication.

If you have severe symptoms that last longer than two weeks, or they clear up and then return, your healthcare provider may also prescribe an anti-inflammatory drug called colchicine (Colcrys® or Gloperba®). Colchicine can help control the inflammation and prevent pericarditis from returning weeks or even months later. Your provider may also prescribe a steroid medicine called prednisone, especially if you have kidney disease that makes it difficult for you to take ibuprofen and colchicine.

If you need to take large doses of ibuprofen, your provider may prescribe medications to ease gastrointestinal (stomach and digestive) symptoms. If you take large doses of nonsteroidal anti-inflammatory drugs (NSAIDs), you’ll 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 constrictive pericarditis causes. If you develop a heart rhythm problem, your provider will talk to you about treatment.

Your provider may also talk to you about treatment with steroids or other medications, such as azathioprine (Azasan® or Imuran®), IV human immunoglobulins or anakinra or rilonacept.

If your pericarditis is caused by an infection, your provider will prescribe specific medicines to treat that infection. If your pericarditis is caused by cancer, the most effective treatment is to treat the cancer.

Procedures and surgeries for pericarditis

When fluid builds 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, a severe compression of the heart that impairs its ability to function. Cardiac tamponade is a medical emergency that requires prompt diagnosis and treatment.

This sudden buildup of fluid in between the layers of the pericardium keeps your heart from working like it should and can cause your blood pressure to drop. Because cardiac tamponade is life-threatening, your provider needs to drain the fluid immediately.

If fluid builds up in your pericardium (pericardial effusion) and compresses your heart, you may need a procedure called pericardiocentesis. Your provider uses a long, thin tube called a catheter to drain the extra fluid. Echocardiography or a CT scan helps guide the catheter and a needle to your pericardium.

If your provider can’t drain the fluid with a needle, they’ll perform a minimally invasive surgical procedure called a pericardial window. They’ll make an opening in the pericardium through a small chest incision to drain fluid from your pericardium.

If you have constrictive pericarditis, you may need to have some of your pericardium removed. This surgery is called a pericardiectomy. Surgeons perform this on people who develop scar tissue in their pericardium. It’s not normally for people who have active inflammation and chest pain from pericarditis.

Surgery isn’t usually used as a treatment for people with pericarditis that keeps coming back because inflammation makes healing after surgery difficult, but your provider may talk to you about it if other treatments aren’t successful.

How long does it take to recover from this treatment?

You should respond to treatment within a week, but you could be taking medicine for two weeks. Recovery from surgery takes longer. It can take weeks or months for a full recovery from pericarditis.

How can I reduce my risk?

Although you can’t prevent acute pericarditis, getting quick treatment and sticking with it can help you reduce your risk of getting it again. You should also follow your provider’s recommendations about when to start exercising again, as brisk exercise can worsen active pericarditis.

What can I expect if I have this condition?

You’ll need to take it easy while recovering from pericarditis. After you recover from pericarditis, you should be able to return to your normal activities without any reason for concern. Don’t return to vigorous exercise until your provider clears you. Your healthcare provider will talk to you about what to expect.

How long does pericarditis last?

Acute pericarditis lasts less than four to six weeks. Incessant pericarditis lasts longer than that but shorter than three months. Chronic pericarditis lasts more than three months. About 15% to 30% of people with pericarditis have repeat (or recurrent) episodes of pericarditis that come and go for many years.

Outlook for this condition

The outlook is very good for people with acute pericarditis who receive treatment. Most people make a full recovery. If you have a mild case, it may get better with rest. Without treatment, some people can end up with chronic pericarditis.

If bacteria or tuberculosis caused your pericarditis, you may have up to a 30% risk of constrictive pericarditis. Cardiac tamponade, a complication of pericarditis, is more likely to happen when cancer or infection causes your pericarditis.

How do I take care of myself?

It’s important to keep taking the medicines your healthcare provider prescribed and to keep all follow-up appointments you have with your provider.

When should I see my healthcare provider?

Contact your healthcare provider if you have symptoms of constrictive pericarditis, including:

• Shortness of breath.
• Swelling in your legs and feet.
• Water retention.
• Heart palpitations.
• Severe swelling of your abdomen.

When should I go to the ER?

Although chest pain is a common symptom of pericarditis, it’s also a symptom of a heart attack. Call 911 if you have chest pain because it could be a heart attack.

What questions should I ask my doctor?

• Do you know what caused my pericarditis?
• How long will I need to take medication?
• What are the chances that I’ll get pericarditis again?

A note from Cleveland Clinic

If you get prompt treatment for pericarditis, you’ll most likely make a full recovery. Continuing with your treatment can help you prevent pericarditis from happening again. That’s why it’s important to keep taking prescribed medicines and go to all of your follow-up appointments. Get familiar with the symptoms of pericarditis so you can get quick treatment if it happens again.