Pericarditis () is inflammation of the pericardium, the fibrous sac surrounding the heart.[ The onset of symptoms can occasionally be gradual rather than sudden.][
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The cause of pericarditis often remains unknown but is believed to be most often due to a viral infection.[ A heart attack may produce similar symptoms to pericarditis.][
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Treatment in most cases is with NSAIDs and possibly the anti-inflammatory medication colchicine.[ Corticosteroid may be used if these are not appropriate.][ Those most commonly affected are males between the ages of 20 and 50.][ Up to 30% of those affected have more than one episode.]
Signs and symptoms
Substernal or left Precordium pleuritic chest pain with radiation to the trapezius ridge (the bottom portion of scapula on the back) is the characteristic pain of pericarditis. The pain is usually relieved by sitting up or bending forward, and worsened by lying down (both recumbent and ) or by inspiration (taking a breath in).
Due to its similarity to the pain of myocardial infarction (heart attack), pericarditis can be misdiagnosed as a heart attack. Acute myocardial infarction can also cause pericarditis, but the presenting symptoms often differ enough to warrant diagnosis. The following table organizes the clinical presentation of pericarditis differential to myocardial infarction:
Physical examinations
The classic medical sign of pericarditis is a pericardial rub Auscultation on the cardiovascular examination, usually on the lower left Sternum.
Complications
Pericarditis can progress to pericardial effusion and eventually cardiac tamponade. This can be seen in people who are experiencing the classic signs of pericarditis but then show signs of relief, and progress to show signs of cardiac tamponade which include decreased alertness and lethargy, pulsus paradoxus (decrease of at least 10 mmHg of the systolic blood pressure upon Inhalation), low blood pressure (due to decreased cardiac index), (jugular vein distention from right sided heart failure and fluid overload), distant heart sounds on auscultation, and equilibration of all the diastolic blood pressures on cardiac catheterization due to the constriction of the pericardium by the fluid.
In such cases of cardiac tamponade, EKG or Holter monitor will then depict electrical alternans indicating wobbling of the heart in the fluid filled pericardium, and the capillary refill might decrease, as well as severe vascular collapse and altered mental status due to hypoperfusion of body organs by a heart that can not pump out blood effectively.
The diagnosis of tamponade can be confirmed with trans-thoracic echocardiography (TTE), which should show a large pericardial effusion and diastolic collapse of the right ventricle and right atrium. Chest X-ray usually shows an enlarged cardiac silhouette ("water bottle" appearance) and clear lungs. Pulmonary congestion is typically not seen because equalization of diastolic pressures constrains the pulmonary capillary wedge pressure to the intra-pericardial pressure (and all other diastolic pressures).
Causes
Infectious
Pericarditis may be caused by virus, , or fungus infection.
In the developing world the bacterial disease tuberculosis is a common cause, whereas in the developed world viruses are believed to be the cause of about 85% of cases.[ Viral causes include coxsackievirus, herpesvirus, mumps virus, and HIV among others.][ Also observed by James Blachly, Strep Throat can also cause pericarditis due to the heart sac filling up.
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Pneumococcus or tuberculous pericarditis are the most common bacterial forms. Anaerobic bacteria can also be a rare cause.
Other
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Idiopathic: No identifiable cause found after routine testing.
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Autoimmune disease: systemic lupus erythematosus, rheumatic fever,
[ IgG4-related disease]
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Myocardial infarction
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Dressler's syndrome
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Peri-Myocardial Infarction Pericarditis
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In August 2024, a team of Japanese researchers analyzed the data stored on the Japanese Adverse Drug Event Report database and investigated the link between Covid-19 vaccination and myocarditis and pericarditis. They found an association between mRNA injections and the heart diseases at statistically significant levels: the reporting odds ratio were 15.64(BNT162b2) and 54.23(mRNA-1273) for myocarditis, and 15.78(BNT162b2) and 27.03(mRNA-1273) for pericarditis.[
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Diagnosis
The preferred initial diagnostic testing is the ECG, which may demonstrate a 12-lead electrocardiogram with diffuse, non-specific, concave ("saddle-shaped"), ST-segment elevations in all leads except aVR and V1
Since the mid-19th century, retrospective diagnosis of pericarditis has been made upon the finding of adhesions of the pericardium.
When pericarditis is diagnosed clinically, the underlying cause is often never known; it may be discovered in only 16–22 percent of people with acute pericarditis.
===Imaging===
On MRI T2-weighted spin-echo images, inflamed pericardium will show high signal intensity. Late gadolinium contrast will show uptake of contrast by the inflamed pericardium. Normal pericardium will not show any contrast enhancement.
Laboratory test
Laboratory values can show increased blood urea nitrogen (BUN), or increased blood Serum creatinine in cases of uremic pericarditis. Generally, however, laboratory values are normal, but if there is a concurrent myocardial infarction (heart attack) or great stress to the heart, laboratory values may show increased cardiac markers like Troponin (I, T), CK-MB, Myoglobin, and LDH1 (lactase dehydrogenase isotype 1).
Classification
Pericarditis can be classified according to the composition of the fluid that accumulates around the heart.
Types of pericarditis include the following:
Acute vs. chronic
Depending on the time of presentation and duration, pericarditis is divided into "acute" and "chronic" forms. Acute pericarditis is more common than chronic pericarditis, and can occur as a complication of infections, immunologic conditions, or even as a result of a heart attack (myocardial infarction), as Dressler's syndrome. Chronic pericarditis however is less common, a form of which is constrictive pericarditis. The following is the clinical classification of acute vs. chronic:
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Clinically: Acute (<6 weeks), Subacute (6 weeks to 6 months) and Chronic (>6 months)
Treatment
The treatment in viral or idiopathic pericarditis is with aspirin,[ Colchicine may be added to the above as it decreases the risk of further episodes of pericarditis.]
Severe cases may require one or more of the following:
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to treat tuberculosis or other bacterial causes
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are used in acute pericarditis but are not favoured. Prednisolone is effective in treating acute viral or idiopathic pericarditis,
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pericardiocentesis to treat a large pericardial effusion causing tamponade
Recurrent pericarditis resistant to colchicine and anti-inflammatory steroids may benefit from a number of medicines that affect the action of interleukin 1; they cannot be taken in tablet form. These are anakinra, canakinumab and rilonacept.[ Rilonacept has been specifically approved as an orphan drug for use in this situation.]
Surgical removal of the pericardium, pericardiectomy, may be used in severe cases and where the pericarditis is causing constriction, impairing cardiac function. It is less effective if the pericarditis is a consequence of trauma, in elderly patients, and if the procedure is done incompletely. It carries a risk of death between 5 and 10%.[
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Epidemiology
About 30% of people with viral pericarditis or pericarditis of an unknown cause have one or several recurrent episodes.
See also
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Acute pericarditis
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Constrictive pericarditis
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Dressler syndrome
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Myopericarditis
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Pericardial effusion
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Purulent pericarditis
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Tuberculous pericarditis
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Uremic pericarditis
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Viral cardiomyopathy
External links
