Acute Pericarditis

Acute pericarditis is a generally painful inflammation of the pericardium that develops suddenly due to injury or disease and causes components of blood to spill into the pericardial cavity.
• Acute pericarditis is caused by injury and Infections that cause inflammation of the pericardium.
• Sharp chest pain which changes with movement, and fever, are the usual symptoms.
• The symptoms and a physical examination can help the doctor make a diagnosis, since the chest sounds characteristic to the condition can be easily picked up by a stethoscope.
• Drugs to control inflammation and pain are administered to patients admitted in the hospital.

When extra fluid enters the pericardial space, it is called pericardial effusion and sometimes an effusion may be due to inflammation. When pericarditis is caused by cancer, an injury to the chest or when it develops after a heart surgery, the fluid accumulated is often blood.

Causes

• An infection or any other condition that causes irritation to the pericardium may result in acute pericarditis. The cause of the infection may be bacteria or viruses such as HIV or influenza virus. Protozoa or other parasitic infestations as well as fungal infections also may cause acute pericarditis.
• In India and Africa, pericarditis resulting from tuberculosis (tuberculosis pericarditis) is very common but in the United States, not even 5% of acute pericarditis in the general population is found to be due to tuberculosis.
• However, according to statistics, pericarditis with pericardial effusion is found to be prevalent among AIDS patients in city hospitals; it could be because people who have AIDS are more prone to tuberculosis or aspergillosis which may result in pericarditis.
• Following a heart attack, in 10 to 15% of cases, acute pericarditis occurs within the first two days and in 1 to 3% cases, sub acute pericarditis develops after10 days to 2 months. Heart surgery also may precipitate pericarditis. Other conditions which may inflame the pericardium include rheumatoid arthritis, rheumatic fever, hypothyroidism, kidney failure etc.
  Leakage of blood from a bulge in the wall of the aorta (aortic aneurysm), Kaposi sarcoma in AIDS patients, cancers such as leukemia, mesothelioma and sharp or blunt injuries to the chest and radiation therapy are some of the other factors that may precipitate acute pericarditis.
• Certain anticoagulant drugs, such as warfarin and heparin, anticonvulsant phenytoin) antibiotic penicillin, antiarrhythmic drug procainamide and a nonsteroidal anti-inflammatory drug phenylbutazone also may cause pericarditis as a side effect.
• Postpericardiotomy syndrome is a type of acute pericarditis which often develops after any surgery which involves the pericardium.
• Subacute pericarditis also results from the same kind of disorders and injuries which cause acute pericarditis. But it is not always possible to determine the exact reason for pericarditis in spite of the many diagnostic tests available.

Symptoms

• The symptoms of acute pericarditis include fever and sharp pain in the chest which may extend to the left shoulder and radiate on to the left arm. The pain often resembles the pain of heart attack, but unlike heart attack, it becomes worse when the patient lies down, or takes a deep breath. The pericardium exerts pressure on the heart, reducing its capacity to function efficiently; and when the pressure is excessive, a life threatening condition called cardiac tamponade may result.
• When tuberculosis is causing pericarditis, it may appear without any symptoms usually associated with a lung infection. On the other hand, fever and symptoms of heart failure, such as fatigue and weakness appear followed by cardiac tamponade.
• When a viral infection causes acute pericarditis, it may be painful but within a few weeks it may disappear without causing any lasting damage.
• After a heart attack, if pericarditis develops after about 10 days and within 2 months, it is often accompanied by a condition called post myocardial infarction syndrome or Dressler syndrome, characterized by joint pain and fever, pleurisy or inflammation of the double walled envelope of the lungs and also pleural effusion, in addition to pericardial effusion.

Diagnosis

• Diagnosis of acute pericarditis is usually possible, based on the description of the characteristic type of pain felt by the patient, and doctors can often confirm it by listening to the sounds picked up by the stethoscope, when placed on the chest. The sounds peculiar to pericarditis is often described either as a crunchy sound, much like the creaking of a leather shoe or as a scratchy sound called pericardial rub, which is like the rustling of dry leaves Doctors often check for these sounds for a few hours to a few days following a heart attack to detect the development of pericarditis.
• An electrocardiogram (ECG) is usually done to assess the abnormalities caused by pericarditis. A chest x-ray and echocardiography can detect pericardial effusion as well as help determine the presence of at least some of the possible causes such as cancer.
• Blood tests can detect some other possible causes of pericarditis such as AIDS, rheumatic fever, leukemia and excess blood urea levels which point to kidney failure.
• When the detection of the cause remains elusive, even after all the above diagnostic tests, a sample of pericardial fluid and sometimes even a bit of pericardial tissue may be extracted and sent for investigations. This test is called pericardiocentesis and it may help identify bacterial infections which can be treated with antibiotics.

Prognosis and Treatment

The prognosis depends on the cause of acute pericarditis. One to three weeks are often required for recovery when pericarditis is due to a viral infection. Recurrences can often slow down and complicate matters. Successful treatment of the cause is the key to treating pericarditis. Prognosis is poor for people with cancer that has spread to the pericardium as their survival beyond a year to 18months is doubtful.

People with pericarditis are usually hospitalized for treatment as well as for diagnostic tests to determine the exact cause. Irrespective of the cause, nonsteroidal anti-inflammatory drugs such as aspirin and ibuprofen are given orally for pain relief, and the patient is closely observed for signs of possible problems like cardiac tamponade. When pain is relieved and inflammation is brought under control, the drugs are tapered off. If any drug taken by the patient is causing the pericarditis, it is immediately stopped.

Corticosteroids like prednisone help reduce inflammation while colchicines may prevent recurrence of pericarditis in addition to relieving pain.

Treatment of acute pericarditis often varies according to the cause. A more frequent dialysis regime usually improves pericarditis in people who have kidney failure. Pericardium is often surgically removed in people with cancer who are undergoing radiation therapy and chemotherapy. If pericarditis is caused by a bacterial infection, draining the pus surgically from the pericardium may be as important as treatment with antibiotics.

Percutaneous balloon pericardiotomy is a minimally invasive surgical procedure, usually performed in case of recurring effusions or when the effusions are due to cancer. In this procedure, a catheter fitted with an inflatable balloon is inserted through the skin, and on reaching the pericardium, the balloon is inflated, creating a small window in the pericardium for drainage of fluid.

Subxiphoid pericardiotomy is another procedure which is very effective, especially for effusions caused by bacterial infections. A thin tube is introduced into the pericardial space via a small incision made right below the breast bone and fluid is allowed to drain continuously. It can be done by the patient’s bed, under local anesthesia.
Ibuprofen, often taken along with colchicine may relieve pain and discomfort in case of acute pericarditis due to an injury, viral infection or some other undetected but recurring disorders.

Symptoms of acute pericarditis often go unnoticed, when it develops within the first two days of a heart attack, but analgesics such as aspirin and morphine which are used to treat the heart attack usually bring relief.

When infections are ruled out, the patient may be given corticosteroids, which may help bring down the severity of symptoms.

The pericardium may be surgically removed if treatment with drugs is not effective.

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