Pericarditis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Pericarditis is a condition in which the sac-like covering surrounding the heart (the pericardium) becomes inflamed. Symptoms of pericarditis include chest pain which increases with deep breathing and lying flat.
Anatomy
The pericardium is a double-walled sac that contains the heart and the roots of the great vessels. Morphologically, it is a conical-shaped, double-walled fibro-serous membrane. It rests posteriorly to the sternum at the level of second to sixth costal cartilages and T5-T8 vertebrae.
Classification
Pericarditis can be classified according to the composition of the inflammatory exudate or the composition of the fluid that accumulates around the heart. It can also be classified into "acute" and "chronic" forms, depending on the timing of presentation and duration.
Pathophysiology
Pericarditis is inflammation of the pericardium, the double-walled sac that contains the heart and the roots of the great vessels. There can be an accompanying accumulation of fluid that can be either serous (free flowing fluid) or fibrinous (an exudate, which is a thick fluid composed of proteins, fibrin strands, inflammatory cells, cell breakdown products, and sometimes bacteria). Vascular congestion of the pericardium is also present. The underlying myocardium may or may not be inflamed as well. If the myocardium is involved in the inflammatory process, then this is called myopericarditis, and the CK and troponin may be elevated.
Causes
Pericarditis is usually a complication of viral infections, most commonly echovirus or coxsackie virus. In addition, pericarditis can be associated with diseases such as autoimmune disorders, cancer, hypothyroidism, and kidney failure. Often the cause of pericarditis remains unknown, or idiopathic.
Differentiating Pericarditis from other Diseases
Signs and symptoms of pericarditis may be similar to several other conditions including myocardial infarction, aortic dissection and pulmonary embolism which are life threatening and therefore it is important to differentiate them. Pain along the trapezius ridge, which is unresponsive to vasodilator therapy and varies with position are signs specific for pericarditis.
Epidemiology and Demographics
Pericarditis most often affects men aged 20 - 50. It usually follows respiratory infections. Pericarditis in developed countries are usually due to viral infections such as echovirus and coxsackie virus, while in developing countries it is usually secondary to tuberculosis or HIV infection. The incidence of pericarditis following MI has greatly reduced with the use of early thrombolytic agents and revascularization.
Natural History, Complications and Prognosis
Pericarditis is often self-limited and most people recover in 2 weeks to 3 months. However, the condition can be complicated by significant fluid buildup around the heart (a pericardial effusion or cardiac tamponade) and may require urgent intervention including pericardiocentesis. If scarring of the sac around the heart (the pericardium) occurs, then this is called constrictive pericarditis which may require surgical stripping of the scar.
Diagnosis
Physical Examination
A careful physical examination must be performed to exclude the presence of cardiac tamponade, a dangerous complication of pericarditis. If cardiac tamponade is present, then pulsus paradoxus, hypotension, an elevated jugular venous pressure and peripheral edema may be present.
EKG
In the presence of a large effusion or tamponade, there may be diminished voltage and electrical alternans (alternation of QRS complex amplitude or axis between beats).
Echocardiography
Echocardiography is generally performed to assess for the presence of a pericardial effusion and to assess and monitor its size. Echocardiography is critical in confirming the clinical suspicion cardiac tamponade.
Treatment
The management of pericarditis depends upon whether the patient has an uncomplicated or a complicated disease course. Uncomplicated pericarditis is generally treated with non-steroidal anti-inflammatory drugs such as ibuprofen in case of viral or idiopathic pericarditis and aspirin in case of post-MI pericarditis.Pericarditis complicated with effusion or cardiac tamponade is generally treated with urgent pericardiocentesis in case of cardiac tamponade, antibiotics in case of purulent pericardial effusion, and steroids or colchicine in patients with recurrent or refractory disease.