Pericarditis

  • Basics

    Pericarditis is an inflammation of the pericardium, the sac-like membrane that surrounds and protects the heart. Figure 01 The pericardium secures the heart in the chest by preventing excessive movement, especially when the position of the body changes. The pericardium also protects the heart from infections in neighboring tissues, and prevents the heart from overfilling with blood.

    Acute pericarditis is sudden inflammation of the pericardium that often causes a distinct type of chest pain. The pain is sharp and may feel like a heart attack, but it tends to be made worse by deep breathing, lying down, or coughing. The pain is the result of the heart rubbing against the irritated pericardium.

    Pericarditis usually occurs in men between the ages of 20 to 50, although women and children are also susceptible. If treated promptly—most commonly with a nonsteroidal anti-inflammatory drug (NSAID)—pericarditis will resolve within a few weeks without permanent damage to the heart.

    Pericarditis can progress to more serious conditions, including chronic forms of pericarditis and the most serious complication of pericarditis, cardiac tamponade. Figure 02

    Chronic pericarditis is a long-lasting inflammation resulting in either gradual fluid accumulation (effusive pericarditis) or slow thickening of the pericardium into scar-like tissue (constrictive pericarditis). The cause of gradual accumulation of fluid is usually unknown. When the pericardium becomes thickened, over years it can contract and compress the heart. The smaller size of the heart impairs its ability to fill with blood. This eventually increases pressure within the veins and causes fluid to back up and accumulate under the skin (peripheral edema), abdomen (ascites), and sometimes around the lungs (pleural effusion, pulmonary edema).

    Cardiac tamponade is usually considered an emergency situation. The fluid within the pericardium increases greatly and quickly, putting excess pressure on the heart. The heart cannot expand completely, limiting the amount of blood leaving the heart and reaching the organs. This situation can result in death if not treated immediately.

    Click to enlarge: Pericarditis

    Figure 01. Pericarditis

    Click to enlarge: Cardiac tamponade

    Figure 02. Cardiac tamponade

  • Causes

    Most cases of pericarditis occur without a clear cause. A case of pericarditis with an unknown cause is called idiopathic pericarditis.

    Common bacterial, viral, and fungal infections can lead to pericarditis. Pericarditis can be caused by bacterial, fungal, or viral infections such as polio, influenza, rheumatic fever, and tuberculosis. The adenovirus and cocksackie viruses are the most common identifiable cause in children. Patients with AIDS often develop infections that trigger pericarditis. Viral infections are a common causes of pericarditis in young, otherwise healthy people.

    Recent heart attack can cause pericarditis. Pericarditis may be triggered by destruction of the heart muscle in a heart attack. Up to 15% of patients who have suffered a heart attack develop pericarditis over ensuing days to weeks. Dressler’s syndrome, a serious and late form of pericarditis following a heart attack, occurs weeks to months after the heart attack.

    Cancer spreading from a nearby tumor can also be the culprit. Cells from tumors in other parts of the body, such as the breast or lungs, can spread to the pericardium, leading to irritation and inflammation. Pericarditis can also result from radiation therapy to treat cancers in the chest.

    Systemic diseases such as kidney failure and lupus erythematosis can cause pericarditis. Pericarditis may occur in patients with uremia, a condition caused by kidney failure and characterized by accumulation of urea and other waste products in the blood. Pericarditis can also develop in patients with diseases in which the immune system becomes overactive and attacks the body's own tissues. Autoimmune disorders that can cause pericarditis include rheumatoid arthritis, lupus, and scleroderma.

    Pericarditis can result from trauma to the chest. Heart damage caused by trauma, such as a severe blow to the chest, a stab wound, or cardiac surgery, can also cause pericarditis. Rupture of the esophagus or infection after heart surgery can lead to a rare form of pericarditis in which the infection produces a lot of purulent drainage, or pus.

    Medications can contribute to immune responses that trigger pericarditis. Medications known to trigger pericarditis include the antibiotic penicillin, the antituberculosis medicine isoniazid (Nydrazid), the antiarrhythmic agent procainamide (Procanbid, Pronestyl), the blood pressure and heart failure medicine hydralazine (Apresoline), and the seizure medication phenytoin (Dilantin).

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