The heart is located in the center of the chest and it is surrounded by an external tunic called pericardium. This coat has two layers, one that perfectly surrounds the muscle of the heart and a flexible layer surrounding the first layer of the pericardium. Inflammation of the pericardium tissue is a potentially serious condition and is called pericarditis.
There are many causes that can lead to pericarditis, but most often the cause of the disease is not known. Among the known causes of pericarditis the most commonly found are: mechanical damage to the heart – heart attack (myocardial infarction), Dressler’s syndrome, surgical intervention, postpericardiotomy syndrome and various types of trauma.
Infections – viral, fungal or HIV.
Cancer – primary (in rare cases) or metastatic
Connective tissue diseases – rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis or scleroderma.
Metabolic diseases – uremia (kidney failure) or hypothyroidism.
Reactions to drugs – side effects of some drugs can cause an immune response that causes inflammation of the pericardial sac. Drugs that may influence the development of pericarditis include phenytoin, hydralazine and procainamide.
Symptoms of pericarditis
- chest pain is the most common symptom of pericarditis;
- pain is often sharp (stabbing);
- pain can occur gradually or suddenly and can radiate to the back, neck or shoulders;
- if irritation of the diaphragm is involved (the muscle that separates the chest from the abdomen), the pain may radiate to the shoulder blades;
- pain may increase when the patient breathes deeply;
- pain is always positional and is amplified when the patient is in horizontal position. In most cases, the pain is relieved when the patient bends forward.
These characteristics of pain can help the doctor distinguish between pericardial inflammation and angina (a condition that causes pain similar to those characteristics of pericarditis, but is caused by narrowing the blood vessels).
Because the heart is located in the mediastinum (the median region of the thorax, which comprises several organs), some symptoms depend on the site of the inflammation: the patient may experience shortness of breath due to pain if the inflammation is located in the pericardium, which is located near the lungs, pain during swallowing can occur if inflammation is near the esophagus.
Other symptoms depend on the specific cause of pericarditis. For example, infections can cause fever, chills and other nonspecific manifestations, such as muscle pain and malaise.
First, for establishing the diagnosis, the doctor will do a physical assessment. It will assess:
- the intensity of the experienced pain
- pattern of pain and the circumstances in which it occurs
- what relieves the pain
- how the chest pain appears (suddenly or gradually) and what other symptoms are present.
Medical history can help the doctor determine easily if there is another possible cause of the chest pain. The most common finding in the case of physical examination, which almost always confirms the diagnosis of pericarditis, is the pericardial friction. The pericardial fluid and the inflammation of the pericardium produce a noise that can be heard with a stethoscope. The sound is sometimes heard better when the patient is leaning forward (position that causes the heart to move in front of the chest).
Other tests that can help diagnose pericarditis include:
- electrocardiogram – in pericarditis, there are anomalies that may help to establish a diagnosis. Unfortunately, many normal versions can mimic changes that occur with pericarditis.
- radiography – imaging test used to detect the expansion of the cardiac tissue and to exclude other conditions that can cause chest pain
- ultrasound echocardiography – helps detect fluid in the pericardial sac, although in mild cases of acute pericarditis, the liquid does not appear on the echocardiography.
- blood tests – are recommended to detect certain cases of pericarditis, including infections, leukemia, kidney failure, connective tissue disease or thyroid abnormalities.
Drugs that reduce inflammation are the treatment of first intention in case of pericarditis.
Anti-inflammatory drugs such as ibuprofen are used to reduce inflammation and the amount of fluid in the pericardial sac. Occasionally, the patient will be prescribed strong painkillers. In recurrent cases (especially when there are immune-mediated cases), corticosteroids can be extremely efficient.
Treatment of the underlying cause of pericarditis is essential and will depend on the severity of the disease. Another treatment option is pericardiocentesis. This is a procedure that involves inserting a thin needle through the chest wall directly into the pericardial sac to drain some of the fluid. Sometimes, the procedure is used in identifying the causes of pericarditis, by analyzing the drained fluid analysis. In severe or recurrent cases, the patient may need either pericardiotomy (the doctor will cut a hole in the pericardial sac) or pericardectomy (complete removal of the pericardial sac).
Complications of pericarditis
– Cardiac tamponade. When there is a large amount of fluid in the pericardial sac, there may be a sharp pressure on the heart, preventing it from working properly. This is a medical emergency and must be treated as such. These symptoms tend to be nonspecific but may include shortness of breath and problems during daily chores.
– Constrictive pericarditis. If the heart or the pericardial sac are injured as a result of trauma or disease affecting the area, there may appear problems with the space. These deficiencies can affect the activity of the heart, hampering the expansion it does in order to collect blood from the body. Bleeding into the pericardium, due to trauma or surgery, are the most common causes of constrictive pericarditis.