Pericarditis

  • Medical Author:
    Benjamin Wedro, MD, FACEP, FAAEM

    Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

  • Medical Editor: Daniel Lee Kulick, MD, FACC, FSCAI
    Daniel Lee Kulick, MD, FACC, FSCAI

    Daniel Lee Kulick, MD, FACC, FSCAI

    Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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What is the treatment for pericarditis?

Most often, pericarditis is caused by a viral infection and the treatment is aimed at decreasing inflammation and controlling pain. Nonsteroidal anti-inflammatory drugs or NSAIDs (ibuprofen [Motrin and others], naproxen [Aleve, Naprosyn, and others]) are commonly used. A short course of narcotic pain medication may be helpful. For other causes of pericarditis, treatment of the underlying cause of pericarditis is essential.

Pericardiocentesis, a procedure where a thin needle is inserted through the chest wall into the pericardial sac, may be considered if a large effusion is present that affects heart function (see cardiac tamponade below).

Pericardotomy (cutting a hole in the pericardial sac) or pericardectomy (removing the sac completely) may be needed for recurrent pericarditis that causes scarring within the pericardial sac and prevents the heart from beating properly.

What are the complications of pericarditis?

Cardiac tamponade

If enough fluid accumulates in the pericardial sac, it can affect heart function and decrease blood pressure. The fluid can accumulate gradually over time or can gather rapidly, depending on the cause. The increased amount of fluid can cause a rise in pressure within the pericardial sac. This causes two potential problems:

  • The ventricles or lower chambers of the heart responsible for pumping blood to the body have difficulty filling with blood because the fluid in the sac prevents them from filling with blood. That means there is less blood to send to the body with each heartbeat.
  • The increased pressure within the pericardium may decrease the amount of blood that can return to the heart. The less blood that returns means there is less to pump out with the next heartbeat.

If a disease causes the pericardial effusion to increase in size slowly, symptoms may come on gradually and the heart can adapt. The symptoms may be nonspecific but can include shortness of breath and difficulty with exercise or doing daily activities. But if the fluid accumulates quickly, like bleeding because of trauma, small amounts of fluid can cause significant problems.

Cardiac tamponade is a medical emergency and the patient may be in shock with low blood pressure, difficulty breathing, and congestive heart failure. The classic findings of cardiac tamponade are:

  • low blood pressure;
  • distended veins in the neck (jugular vein bulging); and
  • muffled heart tones using a stethoscope.

Testing requires emergent EKG, portable chest X-ray, and echocardiogram. Some hospitals are not staffed 24 hours a day by a cardiologist or with an echocardiogram and the diagnosis is often made clinically.

Cardiac tamponade is a true medical emergency that requires pericardiocentesis, a procedure where a long needle is inserted through the chest wall into the pericardial sac and the fluid is removed. This relieves the pressure within the sac and temporarily resolves the acute emergency. A plastic tube or catheter may be left in the chest until the underlying illness that caused the tamponade is treated and stabilized.

Constrictive pericarditis

Recurrent inflammation of the pericardial sac can leading to scarring of the space between the two layers of the pericardial sac. The scarring constricts the movement of the heart during each heartbeat and can prevent the heart from expanding to accept blood returning from the body after each heartbeat. This affects heart function and cardiac output because with less blood returning with each beat there is less that can be pumped out with the next heartbeat.

Bleeding into the pericardium from trauma or from a heart operation is the most common cause of constrictive pericarditis, but tumors, or infections like tuberculosis or fungus, can also be the cause.

The constriction occurs slowly over time and will cause shortness of breath on exertion and decreased ability to exercise. Swelling in the legs and the abdomen may exist because it is difficult for blood to return to the heart and the back pressure in the veins causes fluid to leak out into the tissues.

Diagnosis is made again by history, physical examination, EKG, echocardiography, and sometimes computerized tomography (CT) of the chest.

If there is significant scarring of the pericardial sac, pericardotomy -- an operation to split open the pericardium to free up the constriction -- may be required to improve function. If the whole pericardium must be stripped away from the heart muscle, the procedure is called a pericardectomy.

Medically reviewed by Robert J. Bryg, MD; Board Certified Internal Medicine with subspecialty in Cardiovascular Disease

REFERENCE:

Longo, Dan L., et al. Harrison's Principles of Internal Medicine. 18th ed. McGraw-Hill, 2012.

Medically Reviewed by a Doctor on 11/9/2015

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