Pericarditis is an inflammation of the pericardium, the thin, fluid-filled sac surrounding the heart. It can cause severe chest pain (especially upon taking a deep breath) and shortness of breath.

Pericarditis can be caused by a wide variety of conditions. Most commonly, it occurs in men aged 20 to 50. It can be caused by viral infections, diseases such as cancer or AIDS, or as the result of heart attack, kidney failure, irradiation or injury. In some cases, pericarditis has no known cause (e.g., idiopathic).

Treatment for pericarditis depends on its cause, but most physicians will first try to reduce the pain and inflammation with nonsteroidal anti-inflammatory drugs (NSAIDs). Other drugs that may be prescribed include corticosteroids, which reduce inflammation, or diuretics. Physicians will also attempt to treat the underlying conditions to relieve the inflammation. For instance, antibiotics might be prescribed to treat bacterial pericarditis. In some cases, pericarditis will resolve on its own.

Most patients with pericarditis also have some fluid in the pericardial sac. This condition is known as pericardial effusion and it can cause a number of serious problems. If the buildup of fluid is rapid and severe, it may result in cardiac tamponade.  In this situation, the inflamed pericardial sac fills with fluid and restricts the heart from beating properly. This can be an emergency situation that requires immediate medical attention. If this condition develops, the excess fluid in the pericardium will need to be drained with a needle, catheter or by surgery.

Pericarditis is an inflammation of the pericardium, the thin, fluid-filled sac surrounding the heart. Most patients who have pericarditis also suffer from fluid buildup in the pericardial sac, a condition known as pericardial effusion. If severe, pericardial effusion may be a medical emergency because the fluid in the pericardial sac  puts dangerous pressure on the heart and on a portion of the heart’s major blood vessels. If fluid buildup is fast and heavy enough, it could result in a rare but dangerous condition known as cardiac tamponade, in which the pressure on the heart is so great that it cannot pump enough oxygen-rich blood to the rest of the body.

Pericarditis may be acute (sharp and temporary) or chronic (persistent and recurring). Chronic inflammation can cause the pericardial sac to lose some elasticity, scar and perhaps even adhere to the heart. Consequently, the chambers cannot fully fill with blood. This complication is known as constrictive pericarditis. Constrictive pericarditis can potentially lead to right-sided heart failure.

Though pericarditis often has no known cause (idiopathic pericarditis), there are a number of factors that can influence its development, including:

Other conditions associated with pericarditis include:

• Myocarditis.
  
  
• Kidney failure, leading to uremia (uremic pericarditis).
  
  
• Lupus erythematosus.
  
  
• Cancer (neoplastic pericarditis).
  
  
• Rheumatoid arthritis.
  
  
• Systemic lupus erythematosus.
  
  
• Scleroderma.
  
  
• Chest trauma (due to injury, surgery or radiation therapy).
  
  
• Certain medications.
  
  
• Rheumatic fever. This potentially serious complication of streptococcal (“strep”) infections can result in the inflammation of the myocardium (the heart muscle), the endocardium (the inner lining of the heart’s pumping chambers) or the pericardial sac.
  
  
• Bacterial infection. Bacterial pericarditis (sometimes called purulent pericarditis)  is caused by bacteria such as pneumococcus, strep or staphylococcus. Since the advent of antibiotics, bacterial pericarditis has become relatively rare.
  
  
• Hereditary factors (familial pericarditis).
  
  
• Smallpox vaccine. In rare cases, this vaccine can cause pericarditis.

Younger adults diagnosed with pericarditis are more likely to have pericarditis due to viral infection or unknown causes, whereas older adults generally suffer from trauma-based or cancer-linked causes. Men between the ages of 20 and 50 are most likely to develop pericarditis. Overall, about one in 1,000 patients admitted to the hospital are diagnosed with this condition, although it is believed that many more individuals have a mild form that is never positively diagnosed.

Acute pericarditis is often accompanied by a constant chest pain emanating from the center of the chest beneath the breastbone (sternum). The pain is caused by the inflamed pericardium rubbing against the heart. It may be sharp and stabbing (pleuritis), or radiate to the neck, shoulder, back or abdomen. The pain may be increased with deep breathing, lying flat, coughing or swallowing. Other symptoms may include:

Signs that may be detected by a physician include a rapid pulse or a pulse that is very weak at the end of each deep inhalation (paradoxical pulse). The patient may also show a tendency to lean forward to avoid or relieve the pain. Severe cases may be accompanied by fluid buildup in the space between the lungs and chest wall (pleural effusion). Constrictive pericarditis may also lead to a swelling of the lower extremities or abdomen, as well as bulging (distention) of the neck veins.

After taking a medical history, a physical examination is performed. Auscultation, in which the physician listens to the patient’s heart sounds through a stethoscope, reveals a characteristic pattern, called a pericardial friction rub, in about one-half to two-thirds of patients who are diagnosed with this condition. This is a high-pitched, grating noise thought to be caused by tissue membranes rubbing against each other. There may also be crackles in the lungs, decreased breath sounds or other signs of fluid in the space around the lungs.

A series of diagnostic tests may confirm the presence of pericarditis. In the vast majority of patients in whom pericarditis is suspected, an echocardiogram will be taken. This test involves the use of ultrasound technology to produce three-dimensional images of the heart’s structures and functions.

The echocardiogram will provide information about the presence and extent of any fluid buildup in the pericardium. This test is used mainly to detect pericardial effusion and possibly dangerous cardiac tamponade. However, the absence of pericardial fluid does not rule out the presence of pericarditis. Other tests that may be run include:

• Electrocardiogram (EKG). Measures electrical activity in the heart and will reveal characteristic changes in the wave shape produced as a result of pericarditis. About 90 percent of patients with pericarditis have abnormal EKGs. Changes may occasionally mimic those occurring during a heart attack, but they tend to be more diffuse with pericarditis. In the case of constrictive pericarditis, atrial fibrillation, or abnormally fast rhythms that originate in the upper chambers of the heart, is detected in approximately one-third of patients examined.
  
  
• Blood tests. These tests may be used to determine underlying causes. For example, an elevated sedimentation rate may point to a collagen vascular disorder such as lupus, among others. Blood tests are also used to determine whether the patient is suffering from pericarditis or heart attack, the two may look similar on an EKG test. During a blood test, serum levels of cardiac biomarkers creatine kinase (CK-MB) and cardiac troponin may be measured. Other blood measures that may prove useful include an increased white blood cell count (measured as part of a complete blood count) and C-reactive protein, which shows inflammation in the body.
  
  
• Chest x-ray. May help to identify fluid buildup. The film will show a distinctive rounded shape in the chest area.
  
  
• CAT scan of chest. A noninvasive imaging technique that uses x-ray technology and can identify a thickened pericardium and pericardial fluid.
  
  
• Magnetic imaging resonance. MRI, also a noninvasive or minimaly invasive imaging technique, identifies thickening of the pericardium, abnormalities of the ventricles and calcification (hardening) of the pericardium with a greater resolution than other imaging options.

In general, any patient who exhibits chest pain, has an abnormal EKG and presents with a pericardial friction rub will likely be diagnosed with pericarditis.

Treating pericarditis, including congestive pericarditis (inflammation of the pericardium), often relies on treating the underlying cause, which will relieve the pericarditis. For example, pericarditis caused by rheumatic fever would require treatment with antibiotics, whereas the pericarditis caused by kidney failure would be treated with dialysis. Some cases may require a hospital stay to monitor for signs of cardiac tamponade, present in about 15 percent of cases of acute pericarditis.

If the cause of the condition is not clear, relieving the chest pain and inflammation becomes central to treatment. This may be accomplished through the administration of nonsteroidal anti–inflammatories (NSAIDs), such as aspirin or ibuprofen. These drugs treat the actual inflammation of the pericardium. They may be prescribed at relatively high doses (300 mg to 800 mg, every six to eight hours) for days or weeks, then gradually tapered off as the symptoms receded. In addition, there is evidence that the anti-gout drug cochicline may help relieve the inflammation. This drug may be prescribed in conjunction with NSAIDs. Patients suffering from such chest pain should also refrain from strenuous physical activity.

If the more common anti-inflammatories are not sufficient to relieve symptoms, steroids may be prescribed. These medications are usually effective in alleviating pain by reducing inflammation, but initially prescribed (maximum) dosages should not be used for more than two weeks, as prolonged use increases the risk of bone thinning, high blood pressure, elevated blood sugar, suppression of the immune system and stomach ulcers, among other side effects. 

Diuretics may also be used. These prescription medications are used to remove excess fluid that has accumulated in the pericardial sac.

In severe cases of pericarditis where cardiac tamponade or pericardial effusion is present, a procedure called pericardiocentesis may be required. This treatment involves drainage of the fluid in the pericardial sac through the use of a needle and, if necessary, a catheter. By draining the fluid, pressure against the heart muscle can be relieved and normal blood flow may be restored.

If pericardiocentesis is not successful, or if other complications are present, then further intervention may be necessary, including:

The inflammation associated with acute pericarditis may resolve itself in a matter of weeks. However, there is a possibility of the condition recurring, particularly within two years of the first episode, even if the underlying condition has been successfully treated. This complication affects up to 30 percent of patients with pericarditis, and management is usually possible through the use of anti-inflammatory medications for several months. Left untreated, pericarditis can lead to chronic constrictive pericarditis with subsequent heart failure.

Cardiac tamponade is an emergency condition that requires prompt treatment to avoid serious or even fatal consequences.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following pericarditis-related questions:

1. What underlying conditions might be leading to my pericarditis? What if I can't think of anything that might be causing it?
   
   
2. How long should I take NSAIDs or other anti-inflammatories before we attempt a more invasive procedure to relieve my chest pain?
   
   
3. If we use steroids, will they cause side effects like excess hair growth and other things I've heard about with sex steroids?
   
   
4. How long will I need to be in the hospital if I undergo pericardiocentesis or have surgery?
   
   
5. Is there a chance that I will be dealing with periodic episodes of pericarditis for the rest of my life?
   
   
6. Should I have regular follow-up testing to monitor my pericardium?
   
   
7. Am I at increased risk for other cardiac complications because of pericarditis?
   
   
8. What symptoms should I expect if I have recurrent pericarditis?
   
   
9. Can I exercise? Have sex? What should my exercise program look like?
   
   
10. If I get a viral infection, am I at increased risk of pericarditis? Do I need to take prophylactic antibiotics before going to the dentist?