Pericarditis

Definition:
The pericardium is a thin, two-layered, fluid-filled sac that covers the outer surface of the heart. It shields the heart from infection or malignancy and contains the heart in the chest wall. It also prevents the heart from over-expanding when blood volume increases, which keeps the heart functioning efficiently.
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Pericarditis is an inflammation of the pericardium (the fibrous sac surrounding the heart). A characteristic chest pain is often present.

It can be caused by a variety of causes including viral infections of the pericardium, idiopathic causes, uremic pericarditis, bacterial infections of the precardium (for i.e. Mycobacterium tuberculosis), post-infarct pericarditis (pericarditis due to heart attack), or Dressler’s pericarditis.

If you could see and touch it, the membrane around the heart would look red and swollen, like the skin around a cut that becomes inflamed. Sometimes excess fluid develops in the space between the pericardial layers and causes a pericardial effusion (buildup of excess fluid around the heart).

Classification:
Pericarditis can be classified according to the composition of the inflammatory exudate or in other words the composition of the fluid that accumulates around the heart.

Types include:

*serous
*purulent
*fibrinous
*caseous
*hemorrhagic
*Post infarction

Acute vs. chronic:
Depending on the time of presentation and duration, pericarditis is divided into “acute” and “chronic” forms. Acute pericarditis is more common than chronic pericarditis, and can occur as a complication of infections, immunologic conditions, or even as a result of a heart attack (myocardial infarction). Chronic pericarditis however is less common, a form of which is constrictive pericarditis.

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The following is the clinical classification of acute vs. chronic:
Clinically: Acute (<6 weeks), Subacute (6 weeks to 6 months) and Chronic (>6 months)

 

Symptoms:
Acute pericarditis usually lasts less than a few weeks. Chronic pericarditis usually lasts six months or longer.

If you have acute pericarditis, the most common symptom is sharp, stabbing chest pain behind the breastbone or in the left side of your chest. However, some people with acute pericarditis describe their chest pain as dull, achy or pressure-like instead, and of varying intensity.

The pain of acute pericarditis may travel into your left shoulder and neck. It often intensifies when you lie down or inhale deeply. Coughing, taking a deep breath or swallowing food also may make the pain worse. Sitting up and leaning forward can often ease the pain. At times, it may be difficult to distinguish pericardial pain from the pain that occurs with a heart attack.

Chronic pericarditis is usually associated with chronic inflammation and may result in fluid around the heart (pericardial effusion). The most common symptom of chronic pericarditis is chest pain.

Depending on the type, signs and symptoms of pericarditis may include some or all of the following:

*Sharp, piercing chest pain over the center or left side of your chest, which is worse when taking a deep breath and relieved by sitting forwards – many people think they’re having a heart attack

*Shortness of breath when reclining

*Low-grade fever

*An overall sense of weakness, fatigue or feeling sick

*Dry cough and fatigue

*Fever

*Abdominal or leg swelling

*Pain in the shoulders and neck

Causes:
Under normal circumstances, the two-layered pericardial sac that surrounds your heart contains a small amount of lubricating fluid. In pericarditis, the sac becomes inflamed and the resulting friction from the inflamed sac leads to chest pain.

In some cases the amount of fluid contained in the pericardial sac may increase, causing a pericardial effusion.

The cause of pericarditis is often hard to determine. In most cases doctors are either unable to determine a cause (idiopathic) or suspect a viral infection.

Pericarditis can also develop shortly after a major heart attack, due to the irritation of the underlying damaged heart muscle. In addition, a delayed form of pericarditis may occur weeks after a heart attack or heart surgery because of antibody formation. This delayed pericarditis is known as Dressler’s syndrome. Many experts believe Dressler’s syndrome is due to an autoimmune response, a mistaken inflammatory response by the body to its own tissues — in this case, the heart and pericardium.

Other causes of pericarditis include:

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*Systemic inflammatory disorders. These may include lupus and rheumatoid arthritis.

*Trauma. Injury to your heart or chest may occur as a result of a motor vehicle or other accident.

*Other health disorders. These may include kidney failure, AIDS, tuberculosis and cancer.

*Certain medications. Some medications can cause pericarditis, although this is unusual.

Complication:
Constrictive pericarditis is a severe form of chronic pericarditis in which the inflamed layers of the pericardium stiffen, develop scar tissue, thicken and stick together. The thick, rigid pericardium constricts the heart’s normal movement so that it cannot expand normally as it fills with blood. As a result, the heart chambers don’t fill up with enough blood. The blood then backs up behind the heart, causing symptoms of heart failure, including shortness of breath, swelling of the legs and feet, water retention and disturbances in the heart’s normal rhythm. These symptoms should improve when the constrictive pericarditis is treated.

Constrictive pericarditis often can be treated with a diuretic, such as furosemide, to treat the fluid retention. If you develop a heart rhythm problem, you may need to take a medication to treat the irregular rhythm for as long as the constrictive pericarditis lasts or until your heart rhythm returns to normal. When none of these treatments is effective, pericardiectomy may be needed to surgically remove the stiffened pericardium.

Pericardial Effusion
When an excess of fluid builds up in the space between the pericardium, it can cause a condition known as pericardial effusion. Rapid fluid accumulation in the pericardium can cause cardiac tamponade, a severe compression of the heart that impairs its ability to function. Cardiac tamponade resulting from a pericardial effusion can be life-threatening and is a medical emergency requiring emergent drainage of the fluid with a catheter.

 

 

Diagnosis:
The classic sign of pericarditis is a friction rub auscultated on the cardiovascular examination usually on the lower left sternal border. Other physical signs include a patient in distress, positional chest pain, diaphoresis (excessive sweating), and possibility of heart failure in form of precardial tamponade causing pulsus paradoxus, and the Beck’s triad of hypotension (due to decreased cardiac output), distant (muffled) heart sounds, and JVD (jugular vein distention).

When listening to the heart with a stethoscope, the health care provider can hear a sound called a pericardial rub. The heart sounds may be muffled or distant. There may be other signs of fluid in the pericardium (pericardial effusion).

If the disorder is severe, there may be:

•Crackles in the lungs
•Decreased breath sounds
•Other signs of fluid in the space around the lungs (pleural effusion)

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If fluid has built up in the pericardial sac, it may show on:

•Chest MRI scan
•Chest x-ray
•ECG
•Echocardiogram
•Heart MRI or heart CT scan
•Radionuclide scanning
These tests show:

•Enlargement of the heart
•Signs of inflammation
•Scarring and contracture of the pericardium (constrictive pericarditis)
Other findings vary depending on the cause of pericarditis.

To rule out heart attack, the health care provider may order serial cardiac marker levels (CPK-MB and troponin I). Other laboratory tests may include:

•Blood culture
•CBC
•C-reactive protein
•Erythrocyte sedimentation rate (ESR)
•HIV serology
•Pericardiocentesis, with chemical analysis and pericardial fluid culture
•Tuberculin skin test

Treatment:
The cause of pericarditis must be identified, if possible.

Medications include:

•Analgesics for pain
•Antibiotics for bacterial pericarditis
•Antifungal medications for fungal pericarditis
•Aspirin or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen for inflammation of the pericardium
•Corticosteroids such as prednisone (in some patients)
•Colchicine
If the buildup of fluid in the pericardium makes the heart function poorly or produces cardiac tamponade, it is necessary to drain the fluid from the sac. This procedure, called pericardiocentesis, may be done using an echocardiography-guided needle or minor surgery.

If the pericarditis is chronic, recurrent, or causes constrictive pericarditis, cutting or removing part of the pericardium may be recommended.

Prognosis:
Pericarditis can range from mild cases that get better on their own to life-threatening cases. The condition can be complicated by significant fluid buildup around the heart and poor heart function.

The outcome is good if the disorder is treated promptly. Most people recover in 2 weeks to 3 months. However, pericarditis may come back.

Prevention:
Many cases are not preventable.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose

Resources:
http://www.nlm.nih.gov/medlineplus/ency/article/000182.htm
http://www.mayoclinic.com/health/pericarditis/DS00505
http://en.wikipedia.org/wiki/Pericarditis
http://my.clevelandclinic.org/heart/disorders/other/pericarditis.aspx

http://www.nlm.nih.gov/medlineplus/ency/imagepages/18080.htm

http://fromyourdoctor.com/topic.do?title=Pericarditis&t=8158

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