Pericarditis

Source: Wikipedia, the free encyclopedia.
Pericarditis
NSAIDs, colchicine, corticosteroids[6]
PrognosisUsually good[6][7]
Frequency3 per 10,000 per year[2]

Pericarditis (PER-i-kar-DYE-tis) is inflammation of the pericardium, the fibrous sac surrounding the heart.[8] Symptoms typically include sudden onset of sharp chest pain, which may also be felt in the shoulders, neck, or back.[1] The pain is typically less severe when sitting up and more severe when lying down or breathing deeply.[1] Other symptoms of pericarditis can include fever, weakness, palpitations, and shortness of breath.[1] The onset of symptoms can occasionally be gradual rather than sudden.[8]

The cause of pericarditis often remains unknown but is believed to be most often due to a

electrocardiogram (ECG) changes, and fluid around the heart.[6] A heart attack may produce similar symptoms to pericarditis.[1]

Treatment in most cases is with

NSAIDs and possibly the anti-inflammatory medication colchicine.[6] Steroids may be used if these are not appropriate.[6] Symptoms usually improve in a few days to weeks but can occasionally last months.[3] Complications can include cardiac tamponade, myocarditis, and constrictive pericarditis.[1][2] Pericarditis is an uncommon cause of chest pain.[9] About 3 per 10,000 people are affected per year.[2] Those most commonly affected are males between the ages of 20 and 50.[10] Up to 30% of those affected have more than one episode.[10]

Signs and symptoms

Substernal or left

pleuritic chest pain with radiation to the trapezius ridge (the bottom portion of scapula on the back) is the characteristic pain of pericarditis. The pain is usually relieved by sitting up or bending forward, and worsened by lying down (both recumbent and supine positions) or by inspiration (taking a breath in).[11] The pain may resemble that of angina but differs in that pericarditis pain changes with body position, where heart attack pain is generally constant and pressure-like. Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety.[citation needed
]

Due to its similarity to the pain of myocardial infarction (heart attack), pericarditis can be misdiagnosed as a heart attack. Acute myocardial infarction can also cause pericarditis, but the presenting symptoms often differ enough to warrant diagnosis. The following table organizes the clinical presentation of pericarditis differential to myocardial infarction:[11]

Characteristic Pericarditis Myocardial infarction
Pain description Sharp,
pleuritic
, retro-sternal (under the sternum) or left precordial (left chest) pain 		Crushing, pressure-like, heavy pain. Described as "elephant on the chest."
Radiation Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation. Pain radiates to the jaw or left arm, or does not radiate.
Exertion Does not change the pain Can increase the pain
Position Pain is worse in the supine position or upon inspiration (breathing in) Not positional
Onset/duration Sudden pain, that lasts for hours or sometimes days before a person comes to the ER Sudden or chronically worsening pain that can come and go in
paroxysms
or it can last for hours before the person decides to come to the ER

Physical examinations

The classic

distension of the jugular vein
(JVD). The presence of a triphasic pericardial friction rub on auscultation. A bedside electrocardiogram (ECG) shows widespread concave ST elevation and PR depression throughout most of the limb and precordial leads.

Complications

Pericarditis can progress to pericardial effusion and eventually cardiac tamponade. This can be seen in people who are experiencing the classic signs of pericarditis but then show signs of relief, and progress to show signs of cardiac tamponade which include decreased alertness and lethargy, pulsus paradoxus (decrease of at least 10 mmHg of the systolic blood pressure upon inspiration), low blood pressure (due to decreased cardiac index), (jugular vein distention from right sided heart failure and fluid overload), distant heart sounds on auscultation, and equilibration of all the diastolic blood pressures on cardiac catheterization due to the constriction of the pericardium by the fluid.[citation needed]

In such cases of cardiac tamponade,

altered mental status due to hypoperfusion of body organs by a heart that can not pump out blood effectively.[citation needed
]

The diagnosis of tamponade can be confirmed with

Chest X-ray usually shows an enlarged cardiac silhouette ("water bottle" appearance) and clear lungs. Pulmonary congestion is typically not seen because equalization of diastolic pressures constrains the pulmonary capillary wedge pressure to the intra-pericardial pressure (and all other diastolic pressures).[citation needed
]

Causes

Figure A shows the location of the heart and a normal heart and pericardium (the sac surrounding the heart). The inset image is an enlarged cross-section of the pericardium that shows its two layers of tissue and the fluid between the layers.
Figure B shows the heart with pericarditis. The inset image is an enlarged cross-section that shows the inflamed and thickened layers of the pericardium.[12]

Infectious

Pericarditis may be caused by viral, bacterial, or fungal infection.

In the developing world the bacterial disease

Strep Throat
can also cause pericarditis due to the heart sac filling up.

Candida, and Coccidioides.[citation needed] The most common cause of pericarditis worldwide is infectious pericarditis with tuberculosis.[citation needed
]

Other

In August 2024, a team of Japanese researchers analyzed the data stored on the Japanese Adverse Drug Event Report database and investigated the link between Covid-19 vaccination and myocarditis and pericarditis. They found an association between mRNA injections and the heart diseases at statistically significant levels: the reporting odds ratio were 15.64(BNT162b2) and 54.23(mRNA-1273) for myocarditis, and 15.78(BNT162b2) and 27.03(mRNA-1273) for pericarditis.[20]

Diagnosis

Diffuse ST elevation in a young male due to myocarditis / pericarditis
An ECG showing pericarditis. Note the ST elevation in multiple leads with slight reciprocal ST depression in aVR.

The preferred initial diagnostic testing is the ECG, which may demonstrate a 12-lead

electrocardiogram with diffuse, non-specific, concave ("saddle-shaped"), ST-segment elevations in all leads except aVR and V1[11] and PR-segment depression possible in any lead except aVR;[11] sinus tachycardia, and low-voltage QRS complexes can also be seen if there is subsymptomatic levels of pericardial effusion. The PR depression is often seen early in the process as the thin atria are affected more easily than the ventricles by the inflammatory process of the pericardium.[citation needed
]

Since the mid-19th century, retrospective diagnosis of pericarditis has been made upon the finding of adhesions of the pericardium.[21]

When pericarditis is diagnosed clinically, the underlying cause is often never known; it may be discovered in only 16–22 percent of people with acute pericarditis.[citation needed]

Imaging

  • Ultrasounds showing a pericardial effusion in someone with pericarditis
    Ultrasounds showing a pericardial effusion in someone with pericarditis
  • A pericardial effusion as seen on CXR in someone with pericarditis
    A pericardial effusion as seen on CXR in someone with pericarditis

On MRI

T2-weighted spin-echo images, inflamed pericardium will show high signal intensity. Late gadolinium contrast will show uptake of contrast by the inflamed pericardium. Normal pericardium will not show any contrast enhancement.[22]

Laboratory test

Laboratory values can show increased blood urea nitrogen (

CK-MB, Myoglobin, and LDH1 (lactase dehydrogenase isotype 1).[citation needed
]

Classification

Pericarditis can be classified according to the composition of the fluid that accumulates around the heart.[23]

Types of pericarditis include the following:[citation needed]

  • serous
  • purulent
  • fibrinous
  • caseous
  • hemorrhagic

Acute vs. chronic

Depending on the time of presentation and duration, pericarditis is divided into "acute" and "chronic" forms.

Dressler's syndrome. Chronic pericarditis however is less common, a form of which is constrictive pericarditis. The following is the clinical classification of acute vs. chronic:[citation needed
]

  • Clinically: Acute (<6 weeks), Subacute (6 weeks to 6 months) and Chronic (>6 months)

Treatment

The treatment in viral or idiopathic pericarditis is with

non-steroidal anti-inflammatory drugs (NSAIDs such as ibuprofen).[4] Colchicine may be added to the above as it decreases the risk of further episodes of pericarditis.[4][24]
The drug that helps treat the condition that has developed is aspirin. In this case, the patient is experiencing post-myocardial infarction pericarditis (PIP), which is characterized by chest pain, low-grade fever, and specific findings on physical examination and electrocardiogram. Aspirin is the drug of choice for PIP and is usually already prescribed for secondary prevention following a myocardial infarction. Aspirin acts as an anti-inflammatory drug and helps alleviate the symptoms of pericarditis

Severe cases may require one or more of the following:[citation needed]

  • antibiotics to treat tuberculosis or other bacterial causes
  • steroids are used in acute pericarditis but are not favoured. Prednisolone is effective in treating acute viral or idiopathic pericarditis,
  • pericardiocentesis to treat a large pericardial effusion causing tamponade

Recurrent pericarditis resistant to colchicine and anti-inflammatory steroids may benefit from a number of medicines that affect the action of

interleukin 1; they cannot be taken in tablet form. These are anakinra, canakinumab and rilonacept.[25][26] Rilonacept has been specifically approved as an orphan drug for use in this situation.[27] Immunosuppressive agents, such as Azathioprine and intravenous immunoglobulins, are a novel therapeutic agent which have been effective in treating and preventing recurrent pericarditis, though research on these therapies is limited.[26][28][29][30]

Surgical removal of the pericardium, pericardiectomy, may be used in severe cases and where the pericarditis is causing constriction, impairing cardiac function. It is less effective if the pericarditis is a consequence of trauma, in elderly patients, and if the procedure is done incompletely. It carries a risk of death between 5 and 10%.[26]

Epidemiology

About 30% of people with viral pericarditis or pericarditis of an unknown cause have one or several recurrent episodes.[6]

See also

References

  1. ^ a b c d e f g h i "What Are the Signs and Symptoms of Pericarditis?". National Heart, Lung, and Blood Institute. September 26, 2012. Archived from the original on 2 October 2016. Retrieved 28 September 2016.
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  3. ^ a b "How Is Pericarditis Treated?". National Heart, Lung, and Blood Institute. September 26, 2012. Archived from the original on 2 October 2016. Retrieved 28 September 2016.
  4. ^
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  5. ^ a b "What Causes Pericarditis?". National Heart, Lung, and Blood Institute. September 26, 2012. Archived from the original on 2 October 2016. Retrieved 28 September 2016.
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  8. ^ a b c "What Is Pericarditis?". National Heart, Lung, and Blood Institute. September 26, 2012. Archived from the original on October 2, 2016.
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  10. ^ a b "Who Is at Risk for Pericarditis?". National Heart, Lung, and Blood Institute. September 26, 2012. Archived from the original on 2 October 2016. Retrieved 28 September 2016.
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  12. ^ "Pericarditis". National Heart, Lung, and Blood Institute .nih.gov. Archived from the original on 8 August 2014. Retrieved 5 August 2014.
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  16. ^ Gharacholou S Michael; Vaca-Cartagena F Bryan; Parikh P Pragnesh; Pollak M Peter; Bruce J Charles. "Peri-Myocardial Infarction Pericarditis: Current Concepts". Edelweiss Publications Inc. Retrieved 15 February 2022.
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  18. ^ "Myocarditis, Pericarditis, and Dilated Cardiomyopathy after Smallpox Vaccination among Civilians in the United States, January–October 2003". 15 March 2008. Retrieved 22 January 2022.
  19. ^ "Myocarditis and Pericarditis After mRNA COVID-19 Vaccination". Retrieved 22 January 2022.
  20. ^ Takada, K. (Aug 2024). "SARS-CoV-2 mRNA vaccine-related myocarditis and pericarditis: An analysis of the Japanese Adverse Drug Event Report database". Journal of Infection and Chemotherapy.
  21. ^ Flint A (1862). "Lectures on the diagnosis of diseases of the heart: Lecture VIII". American Medical Times: Being a Weekly Series of the New York Journal of Medicine. 5 (July to December): 309–311.
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  23. ^ Klatt EC. "Cardiovascular Pathology Index Images". The Internet Pathology Laboratory for Medical Education. Florida State University College of Medicine. Archived from the original on 2007-05-24.
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  27. ^ Center for Drug Evaluation and Research (18 March 2021). "FDA Approves First Treatment for Disease That Causes Recurrent Inflammation in Sac Surrounding Heart". FDA. U.S. Food and Drug Administration. Archived from the original on March 18, 2021. Retrieved 19 March 2021.
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