Pericarditis

What happens in pericarditis

The pericardium has two thin layers with a small amount of lubricating fluid between them, letting the heart beat smoothly. When the layers become inflamed, they rub against each other with each heartbeat, causing pain. Inflammation can also cause extra fluid to collect between the layers (pericardial effusion).

Doctors describe pericarditis by its course:

• Acute: a first episode lasting less than 4 to 6 weeks
• Incessant: lasting more than 4 to 6 weeks without remission
• Recurrent: returning after a symptom-free gap of at least 4 to 6 weeks
• Chronic: lasting more than 3 months

Symptoms

• Chest pain: sharp, stabbing or pleuritic (worse with breathing), usually behind the breastbone or on the left side. It often spreads to the neck, shoulders or the ridge of the trapezius muscle on top of the shoulder.
• Pain changes with position: worse lying flat, better sitting up and leaning forward.
• Pain worse with deep breaths, coughing or swallowing.
• Low-grade fever
• Shortness of breath, especially lying down
• Palpitations
• Tiredness and feeling unwell
• Cold or flu-like symptoms in the days or weeks before, in viral cases

Causes

In wealthy countries, 80% to 90% of cases are viral or idiopathic (no cause found, assumed viral). Other causes include:

Pericarditis vs heart attack

Chest pain should always be taken seriously, and doctors will rule out a heart attack. These clues help tell them apart:

Myocarditis, inflammation of the heart muscle, can occur together with pericarditis (myopericarditis). A raised troponin level suggests the muscle is involved.

How pericarditis is diagnosed

Doctors diagnose acute pericarditis when at least two of these four are present:

1. typical chest pain
2. a pericardial friction rub, a scratchy, squeaky sound heard with a stethoscope
3. characteristic ECG changes
4. new or worsening pericardial effusion on an echocardiogram

Other tests:

• Blood tests: CRP and white cell count to measure inflammation, troponin to check heart muscle, kidney function, and sometimes autoimmune and TB tests
• Chest X-ray: to look for an enlarged heart shadow or lung problems
• Echocardiogram: ultrasound of the heart to check for fluid and heart function
• Cardiac MRI: shows pericardial inflammation and myocarditis in unclear or recurrent cases

Treatment

Most people with uncomplicated pericarditis are treated at home. Hospital admission is advised for high fever over 38 °C (100.4 °F), a large effusion, tamponade, a slow start of symptoms over weeks, failure to improve after a week of NSAIDs, raised troponin, a weak immune system, or use of blood thinners.

Medicines

• NSAIDs or aspirin: high doses (prescribed by your doctor) for 1 to 2 weeks, then tapered. Aspirin is preferred after a heart attack. Doctors usually add a stomach-protecting medicine.
• Colchicine: taken for 3 months (6 months for recurrences). It speeds recovery and roughly halves the risk of recurrence. Side effects are mainly diarrhea and stomach upset.
• Corticosteroids: used only when NSAIDs and colchicine cannot be taken or do not work, or for autoimmune causes. They increase the chance of recurrence if used first-line.
• IL-1 blockers (such as anakinra or rilonacept): for recurrent pericarditis that keeps returning despite standard treatment.
• Treating the cause: antibiotics for bacterial infection, TB treatment, dialysis for kidney failure, cancer therapy.

Rest and activity

Avoid strenuous exercise until symptoms are gone and CRP has normalized. Athletes are usually advised to wait at least 3 months before returning to competitive sport, longer if myocarditis was present.

Procedures

• Pericardiocentesis: draining fluid with a needle guided by ultrasound, for tamponade or a large effusion
• Pericardiectomy: surgical removal of the pericardium, for constrictive pericarditis or frequent recurrences that do not respond to medicines

Complications

• Recurrence: in about 15% to 30% of people, mostly within 18 months, more often without colchicine
• Cardiac tamponade: fluid builds up fast enough to compress the heart, causing low blood pressure and shock; needs urgent drainage
• Constrictive pericarditis: the pericardium thickens and stiffens, restricting the heart's filling and causing swelling of the legs and belly. It is uncommon after viral pericarditis but more frequent after TB, bacterial infection or radiation.

Recovery and outlook

Most people with viral or idiopathic pericarditis recover completely. Pain usually eases within a few days of starting treatment, and most people feel back to normal within 1 to 3 weeks. Some tiredness can last longer. Taking colchicine for the full course and avoiding strenuous exercise until inflammation has settled lowers the chance of it coming back. Recurrent pericarditis can be frustrating but rarely damages the heart.

Frequently asked questions

What does pericarditis pain feel like?

Usually a sharp, stabbing pain behind the breastbone or on the left side of the chest. It typically gets worse when you breathe in deeply, cough or lie flat, and improves when you sit up and lean forward. It may spread to the neck or top of the shoulders.

How long does pericarditis last?

Most acute episodes settle within 1 to 3 weeks with treatment. Colchicine is usually continued for 3 months to prevent recurrence. About 1 in 4 people have a recurrence, which may need longer treatment. Chronic pericarditis lasts more than 3 months.

Is pericarditis serious?

Usually not. Most cases are mild and resolve fully with anti-inflammatory medicine. Serious complications, such as fluid compressing the heart (tamponade) or a stiff, constricting pericardium, are uncommon. Chest pain with breathlessness, fainting or dizziness needs emergency care.

Can stress cause pericarditis?

Stress does not directly cause pericarditis. Most cases follow a viral infection or have no clear cause. Some people notice flares of recurrent pericarditis during stressful or run-down periods, possibly because of infections or overexertion, but the link is not proven.

Can I exercise with pericarditis?

Avoid strenuous exercise until your symptoms have gone and blood tests show inflammation has settled, usually at least several weeks. Competitive athletes are generally advised to wait 3 months. Gentle walking is usually fine once pain allows. Check with your doctor before restarting training.

What is the difference between pericarditis and myocarditis?

Pericarditis affects the sac around the heart, while myocarditis affects the heart muscle itself. They can occur together. Myocarditis is suspected when troponin, a marker of muscle damage, is raised, and it needs longer rest from exercise and closer heart monitoring.