Brief overview
- Description: In pericarditis the outer connective tissue layer of the heart is inflamed. A distinction is made between acute, chronic and constructive pericarditis (armored heart) and perimyocarditis.
- Symptoms: Symptoms of pericarditis include fever, cough, an altered heartbeat, water retention (edema), and visibly congested neck veins.
- Treatment: Treatment depends on the cause of the pericarditis. In addition, physical rest, ibuprofen, and colchicine are often useful.
- Course and prognosis: Because of numerous possible complications of the disease, pericarditis can be life-threatening.
- Examinations and diagnosis: An exact, specific anamnesis is indicative. This is followed by a physical examination in which the heart and lungs are listened to. In addition, blood work, ECG (electrocardiogram), cardiac echo (echocardiography), chest x-ray, MRI, and pericardiocentesis are among the possible further procedures.
Pericarditis: Description
Pericarditis is the inflammation of the connective tissue covering that completely surrounds the heart. It can be caused by pathogens such as viruses or bacteria, but also by non-infectious reactions of the immune system.
Pericarditis can be fatal if not treated properly and in time.
Structure and function of the pericardium
The pericardium consists of a firm, barely stretchable connective tissue. It holds the heart in place. In addition, the pericardium protects the delicate heart muscle and its blood vessels. About 20 to 50 ml of fluid circulates between the pericardium and the heart muscle. This reduces friction with each heartbeat.
Acute pericarditis
Infections, but also other diseases, for example of the rheumatic type, can trigger acute pericarditis. In addition, pericarditis can also be the result of a heart attack. In this case, the dead heart muscle parts cause an inflammatory reaction. It can occur a few days after a heart attack, when the inflammation spreads to the adjacent pericardium (early pericarditis, pericarditis epistenocardia). More rarely, the pericardium becomes inflamed weeks after the myocardial infarction (Dressler’s syndrome, late pericarditis).
If white-yellowish fibrin coatings form during inflammation (similar to an abrasion when it closes), it is called fibrinous acute pericarditis.
In some cases, pericarditis is bloody, for example as a result of heart surgery, after a heart attack or in the case of tuberculosis. Tumors or metastases growing into the pericardium can also cause bloody inflammation.
Chronic pericarditis
Chronic pericarditis often develops when acute pericarditis does not heal completely (despite treatment) and keeps flaring up. How long a patient is sick with pericarditis naturally results from individual differences. However, it usually heals within one to three weeks. In this case, it is not a chronic form.
If, on the other hand, pericarditis persists for more than three months, it is referred to as chronic pericarditis. It can also develop without an acute history. For example, tuberculosis, rheumatic diseases, some medications, or even medical radiation (for example, in the case of a lung tumor) may cause chronic pericarditis.
Armored heart (constrictive pericarditis)
Perimyocarditis
Since the pericardium is located close to the heart muscle, both structures are sometimes inflamed at the same time. In medical terms, this is called perimyocarditis. It is not so easy to distinguish pericarditis (inflammation of the pericardium) from perimyocarditis (inflammation of the heart muscle). However, this is not mandatory, since the treatment often does not change. However, this is then done in the hospital, as the risk of complications is increased.
Pericarditis: Symptoms
Typical symptoms of acute pericarditis are pain behind the breastbone (retrosternal pain) or throughout the chest. The pain may also radiate to the neck, back, or left arm and worsens with inhalation, coughing, swallowing, or changes in position. People with acute pericarditis also often have a fever.
In some cases, the heartbeat accelerates (tachycardia). Cardiac arrhythmias and a feeling of heart stumbling also occur with pericarditis. Depending on the severity of the condition, shortness of breath and chest tightness may occur. Similar symptoms may also occur in pneumonia with pleurisy, lung collapse (pneumothorax), or especially in acute myocardial infarction.
You should always have the cause of acute chest pain clarified immediately!
In the case of pericarditis, which is chronic from the start, the symptoms usually develop gradually. It therefore often remains unnoticed for a long time. In addition to general symptoms of inflammation such as dullness and reduced performance, symptoms of cardiac insufficiency may also occur as scarring and thickening of the pericardium progress:
- Accelerated heartbeat and flatter pulse
- Shortness of breath during physical exertion (later also at rest)
- Cough
- congested (visibly protruding) neck veins
- Water retention (edema)
- “Paradoxical pulse” (pulsus paradoxus = drop of the systolic, i.e. upper blood pressure value by more than 10 mmHg when breathing in)
Complication of pericardial tamponade
Pericardial tamponade is a life-threatening complication of pericarditis. It occurs when a large amount of blood, pus, and/or inflammatory fluid rapidly accumulates in the pericardium. Because the pericardium is not expandable, the effusion constricts the heart muscle and the heart chambers cannot expand properly.
As a result, less blood is pumped to the lungs (from the right ventricle) or to the systemic circulation (from the left ventricle). Blood pressure drops, and the heart races. In addition, blood backs up into the veins, which can be seen in the prominent neck veins.
Sufferers have difficulty breathing, suddenly appear pale and sweat. The circulation may collapse. Pericardial tamponade is acutely life-threatening and must be treated immediately.
Pericarditis: symptoms in women during pregnancy.
Symptoms of pericarditis do not differ in men and women. Special features exist in women basically only during pregnancy.
The heart is exposed to greater stress during pregnancy. After all, it is now supposed to transport blood for at least two people. In the last trimester of pregnancy, therefore, a so-called hydropericardium is often found. A hydropericardium is a small effusion that occurs in about 40 percent of pregnant women after the sixth month.
Pericarditis during pregnancy is also a possibility. However, the treatment hardly differs from the therapy of non-pregnant patients. However, the drugs used are checked to see whether they are approved for use during pregnancy. There may therefore be deviations here.
In patients with recurrent or chronic pericarditis, it is best to plan the pregnancy so that it falls in a period when the symptoms are less severe.
Pericarditis: Treatment
Because pericarditis has different triggers depending on the patient, the question of what to do about pericarditis is not easy to answer. The therapy always depends on the individual causes.
The first measure to be taken in the event of pericarditis is physical rest to relieve the heart. Pericarditis is usually treated on an outpatient basis. Patients do not have to stay in the hospital. They are then given anti-inflammatory drugs, for example NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen, ASA or even colchicine. Antiviral drugs are not used (or only in individual cases).
In some cases, however, certain circumstances increase the risk of a complicated course of pericarditis. In such cases, patients are treated in hospital. Fever above 38 degrees or a large pericardial effusion, for example, are among these risk factors.
If a specific cause of pericarditis is known, it determines the further treatment (causal therapy):
Antibiotics are prescribed for bacterial infections. They are often given as an infusion so that they work better.
In the case of fungal infections, antifungal agents, so-called antimycotics, are used. These are also often administered as short infusions.
If kidney failure is the cause of pericarditis, the blood must be purified by dialysis.
The success of the treatment is monitored by regular ultrasound examinations of the heart. In the case of chronic pericarditis with thickening and scarring of the pericardium (armored heart), the pericardium must be (partially) removed in an open-chest operation called pericardiectomy.
There are no home remedies that help with pericarditis or relieve the symptoms. The only thing that really helps is physical rest.
Treatment of pericardial tamponade
Pericardial tamponade is when so much fluid collects in the pericardium that heart function is affected. It is life-threatening and must be treated immediately. For this purpose, the pericardium is punctured from the outside through the thorax with a needle under ultrasound control (sonography) and the effusion fluid is drawn off. The affected person must then be closely monitored sonographically in order to detect any leakage of effusion fluid or blood at an early stage.
Pericarditis: course and prognosis
Pericarditis is a serious disease. It can spread to the heart muscle (perimyocarditis) or the entire heart (panicarditis). The effusion (serous fluid, pus or blood) that sometimes develops can dangerously constrict the heart muscle. If pericarditis is recognized early and its causes and consequences are treated, it can heal without consequences. If left untreated, pericarditis is a life-threatening condition due to its severe complications (armored heart and pericardial tamponade).
Pericarditis: examinations and diagnosis
If pericarditis is suspected, in most cases, affected individuals are referred to a specialist cardiology practice. The cardiologist first asks about the medical history:
- How long have the symptoms been present?
- Have the symptoms increased or have new symptoms developed?
- Do you feel less able to cope with physical strain?
- Do you have a fever – and if so, since when?
- Have you had an infection in the past weeks – especially of the respiratory tract?
- Does your chest pain change when you breathe or lie down?
- Have you had any previous complaints or diseases of the heart?
- Do you have any known rheumatism or other immune system disease?
- What medications are you taking?
A blood sample is taken to look for typical markers of inflammation or infection. Therefore, if pericarditis is suspected, the following blood values are of interest:
- Accelerated erythrocyte sedimentation rate
- Increased CRP value
- Increase in white blood cells (leukocytosis in the case of bacteria or fungi, lymphocytosis in the case of viruses)
- Detection of bacteria in blood culture
- Increased cardiac enzyme values (CK-MB, troponin T)
- Elevated so-called rheumatoid factors
Various instrumental examinations subsequently confirm the suspected diagnosis of pericarditis:
- ECG: In pericarditis, the ECG shows abnormal ST-segment elevation, flatter or negative T waves, or, in the case of pericardial effusion, overall decreased beats (low voltage). This is how pericarditis can be detected on the ECG.
- Echocardiography (“heart ultrasound”) to detect an effusion.
- X-ray examination of the chest (“X-ray thorax”, only shows large effusions due to enlarged heart shadow)
- Magnetic resonance imaging (MRI) or computed tomography (CT) to visualize the pericardial wall and any existing effusion
- Pericardiocentesis (if effusion is present) to unload the heart, assess its condition, and attempt to detect a pathogen
Pericarditis: causes and risk factors
However, other conditions or treatments can also cause pericarditis. These include:
- Kidney failure with elevated uric acid levels in the blood.
- Autoimmune diseases and rheumatic diseases
- Metabolic disorders (hypothyroidism or hypercholesterolemia)
- Consequences of a heart attack
- Heart operations (postcardiotomy syndrome)
- Tumor diseases
- Radiation therapy
Pericarditis caused by stress is not known in everyday medicine. However, stress can increase the risk of a heart attack. This then develops into pericarditis in some patients. In such a case, pericarditis is therefore only secondary – but not directly – to stress and psychological pressure.
