Pericarditis

Pericarditis is inflammation of the pericardium (the fibrous sac surrounding the heart). Symptoms typically include sudden onset of sharp chest pain. The pain may also be felt in the shoulders, neck, or back. It is typically better sitting up and worse when lying down or breathing deeply. Other symptoms may include fever, weakness, palpitations, and shortness of breath. Occasionally onset of symptoms is gradual.Ultrasounds showing a pericardial effusion in someone with pericarditisA pericardial effusion as seen on CXR in someone with pericarditis Pericarditis is inflammation of the pericardium (the fibrous sac surrounding the heart). Symptoms typically include sudden onset of sharp chest pain. The pain may also be felt in the shoulders, neck, or back. It is typically better sitting up and worse when lying down or breathing deeply. Other symptoms may include fever, weakness, palpitations, and shortness of breath. Occasionally onset of symptoms is gradual. The cause of pericarditis is believed to be most often due to a viral infection. Other causes include bacterial infections such as tuberculosis, uremic pericarditis, following a heart attack, cancer, autoimmune disorders, and chest trauma. The cause often remains unknown. Diagnosis is based on the chest pain, a pericardial rub, specific electrocardiogram (ECG) changes, and fluid around the heart. Other conditions that may produce similar symptoms include a heart attack. Treatment in most cases is with NSAIDs and possibly colchicine. Steroids may be used if those are not appropriate. Typically symptoms improve in a few days to weeks but can occasionally last months. Complications can include cardiac tamponade, myocarditis, and constrictive pericarditis. It is a less common cause of chest pain. About 3 per 10,000 people are affected per year. Those most commonly affected are males between the ages of 20 and 50. Up to 30% of those affected have more than one episode. Substernal or left precordial 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). 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. 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: The classic sign of pericarditis is a friction rub heard with a stethoscope 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); possibility of heart failure in form of pericardial tamponade causing pulsus paradoxus, and the Beck's triad of low blood pressure (due to decreased cardiac output), distant (muffled) heart sounds, and distension of the jugular vein (JVD). Pericarditis can progress to pericardial effusion and eventually cardiac tamponade. This can be seen in patients 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. In such cases of cardiac tamponade, EKG or Holter monitor will then depict electrical alternans indicating wobbling of the heart in the fluid filled pericardium, and the capillary refill might decrease, as well as severe vascular collapse and altered mental status due to hypoperfusion of body organs by a heart that can not pump out blood effectively. The diagnosis of tamponade can be confirmed with trans-thoracic echocardiography (TTE), which should show a large pericardial effusion and diastolic collapse of the right ventricle and right atrium. 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).