The heart sits in the center of the chest and is surrounded by a sac called the pericardium. This sac has two layers, one that fits tightly onto the heart muscle and another looser layer surrounding the inner layer. Inflammation of these tissue layers surrounding the heart is referred to as pericarditis.

Pericarditis occurs in up to 15% of patients who have acute myocardial infarctions (heart attacks). There is also a late form of post-heart-attack pericarditis, called Dressler's syndrome, that occurs weeks to months after the heart attack.

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. What are the symptoms of Pericarditis? A symptom is something the patient senses and describes, while a sign is something other people, such as the doctor notice. For example, drowsiness may be a symptom while dilated pupils may be a sign.

The most common symptom caused by pericarditis is chest pain. The pain can be severe, and is often made worse by changing position or with deep breathing. Patients can also have shortness of breath, or fever.

The pain is usually sharp and stabbing. It can arise slowly or suddenly and can radiate directly to the back, to the neck or to the arm.

If there is associated irritation of the diaphragm, the pain can radiate to the shoulder blade, and the pain can be made worse with deep breaths. The pain is frequently positional and made worse when lying flat and better when leaning forward.

While pericarditis usually resolves within a few days or a few weeks, three complications can occur. These are tamponade, chronic pericarditis, or constrictive pericarditis. Tamponade occurs when fluid accumulating in the pericardial sac (a condition called pericardial effusion) prevents the heart from filling completely. When this happens, the blood pressure drops and the lungs become congested, and the patient experiences weakness, dizziness and lightheadedness, and extreme shortness of breath. If treatment is not given, death can occur.

Chronic pericarditis occurs when the pericardial inflammation does not resolve within a few weeks. It can be associated with all the symptoms of acute pericarditis, and in addition is often accompanied by particularly large pericardial effusions. Constrictive pericarditis occurs when a chronically inflamed pericardial sac sticks to the heart muscle, squeezing and constricting it. The symptoms are the same as with tamponade, but usually have a much more gradual onset.

Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety. Due to similarity to myocardial infarction or heart attack pain, pericarditis can be misdiagnosed as a heart attack soley based on the clinical data and so extreme suspicion on the part of the diagnostician is required.

Ironically an acute myocardial infarction (heart attack) can also cause pericarditis, but often the presenting symptoms vary enough to warrant a diagnosis. What are the causes of Pericarditis? In many cases, no definite cause for pericarditis can be identified. This is called idiopathic pericarditis.

Pericarditis can be caused by infection, heart attack, autoimmune disorders, chest trauma, cancer, kidney failure, or drugs.

Infections that can cause pericarditis include viral infections, bacterial infections, tuberculosis, and fungal infections. Patients with AIDS frequently develop infections that produce pericarditis. Autoimmune disorders that can cause pericarditis include rheumatoid arthritis, lupus, and scleroderma. Some of the drugs that can produce pericarditis include procainamide, hydralazine, phenytoin, and isoniazid.

Many forms of cancer can metastasize to the pericardial sac, and produce pericarditis.

Diagnosing Pericarditis The diagnosis of pericarditis is usually first suggested by development of chest pain that worsens with taking a deep breath or lying down and that improves with sitting up and leaning forward. Chest pain from pericarditis is usually a sharp pain coming from the left side of the chest underneath the breastbone. The pain might radiate into the left arm or into the neck. Chest pain occurs because the pericardium is pressing up against the outer part of the heart.

The initial evaluation consists of a medical history and a physical examination. The medical history focuses on chest pain: Does the pain get worse when the patient takes a deep breath? Is it worse when they lie down? A doctor or nurse usually inquires about recent infections, a history of coronary artery disease or myocardial infarction, symptoms that might suggest the presence of cancer, and medications that are being taken need to be disclosed, as some medications can cause pericarditis.

Several tests are also available for diagnosis of pericarditis. First, an EKG (electrocardiogram) is a simple test detects and records the heart's electrical activity. Certain EKG results suggest pericarditis.

A chest x ray creates pictures of the structures inside the chest, such as the heart, lungs, and blood vessels. The pictures can show whether a patient has an enlarged heart. This is a sign of excess fluid in the pericardium.

An echocardiography is a painless test that uses sound waves to create pictures of the heart. The pictures show the size and shape of the heart and how well it is working. This test can show whether fluid has built up in the pericardium or not.

Finally, a cardiac MRI uses powerful magnets and radio waves to create detailed pictures of your organs and tissues. A cardiac MRI can show changes in the pericardium.

A doctor also may recommend blood tests. These tests can help find out whether if a patient has had a heart attack, the cause of pericarditis, and how inflamed your pericardium is. What are the treatment options for Pericarditis? Medicines that reduce inflammation are the primary treatment for pericarditis in clued nonsteroidal anti-inflammatory drugs, such as ibuprofen, that decrease the inflammation and fluid accumulation in the pericardial sac.

Occasionally, a short course of narcotic pain medication such ascodeine, hydrocodone or oxycodone will be needed. In recurrent cases, especially in immunologically-mediated causes, corticosteroids are often very effective. Treatment of the underlying cause of pericarditis is essential and will be based on the disease process.

Pericardiocentesis, a procedure where a thin needle is inserted through the chest wall into the pericardial sac, may be considered if too much fluid is present, or to aid in establishing the cause of the pericarditis by analyzing the fluid that is removed.

Pericardotomy or pericardectomy (removing the sac completely) may be needed for recurrent pericarditis or scarring within the pericardial sac. Preventing Pericarditis You usually can't prevent acute pericarditis. You can take steps to reduce your chance of having another acute episode, having complications, or getting chronic pericarditis.

These steps include getting prompt treatment, following your treatment plan, and having ongoing medical care.

Sy Kraft (B.A.)

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