Pericarditis

Pericarditis

Introduction

Pericarditis is swelling of the pericardium, which is the fluid-filled sac surrounding your heart.

The main symptom of pericarditis is chest pain. This can be a sudden, sharp and stabbing pain behind your breastbone or more of a dull ache. The pain is often worse when lying down or breathing in, and better when sitting up.

Pericarditis is not usually a serious condition and may be treated on an outpatient basis, so you don’t have to be admitted to hospital.

Read more about the symptoms of pericarditis.

Types of pericarditis

There are three main types of pericarditis:

  • acute pericarditis – where the symptoms last less than three months (with treatment, symptoms normally resolve within a week) and often appear after flu-like symptoms
  • recurring pericarditis – where someone has repeated episodes of acute pericarditis
  • chronic pericarditis – a complication of pericarditis, where the symptoms last longer than three months

Why does pericarditis happen?

In most cases of pericarditis, no cause is identified. However, an infection is usually thought to be responsible.

Other things that may cause pericarditis include chest injury, some cancers and some treatments, such as radiotherapy or chemotherapy.

Problems with the body’s immune system may also play a role in recurring and chronic pericarditis.

Read more about the causes of pericarditis.

How is pericarditis treated?

Acute pericarditis can usually be treated with medication to reduce swelling, such as non-steroidal anti-inflammatory drugs (NSAIDs), although antibiotics may be used if there is a bacterial infection.

A medication called colchicine is often used for recurring pericarditis, as it can prevent symptoms returning.

Treatment for chronic pericarditis will depend on the underlying cause. Some cases respond well to medication, while others may require surgery.

Read more about treating pericarditis.

Cardiac tamponade

In rare cases, pericarditis can trigger a serious complication known as cardiac tamponade. This is an excess build-up of fluid inside the pericardium. The extra fluid places too much pressure on the heart, so it is unable to beat properly.

Cardiac tamponade can cause symptoms such as:

  • light-headedness
  • blurred vision
  • palpitations
  • nausea

Cardiac tamponade also often occurs alongside inflammation of the heart muscle (myocarditis). This causes pain that feels like pressure on the chest, similar to a heart attack.

Cardiac tamponade is life-threatening and requires emergency treatment. If you have a history of pericarditis and develop the symptoms listed above, call 999 and ask for an ambulance.

Read more about the complications of pericarditis.

Who is affected?

Pericarditis is a relatively common heart condition. Around 5% of all admissions to accident and emergency (A&E) departments for severe chest pain are diagnosed as pericarditis.

Pericarditis tends to be more common in men than women. It can affect people of all ages, but mostly occurs in young adults.

Symptoms of pericarditis

Causes of pericarditis

It’s not always clear what causes pericarditis, although a viral infection is usually suspected.

In around 90% of acute pericarditis cases, no obvious cause can be found to explain why the pericardium has become inflamed. This is known as idiopathic pericarditis. 

Many cases are thought to be the result of viral infections, which can’t be detected.

Viral infections

Viral infections associated with acute pericarditis include:

Other causes

Other less common causes of acute pericarditis include:

  • bacterial infection, particularly tuberculosis
  • autoimmune conditions such as rheumatoid arthritis or lupus, where the immune system attacks healthy tissues
  • radiotherapy – the radiation used in radiotherapy can damage the tissue of the pericardium, and breast cancer or lung cancer patients may be at particular risk
  • kidney failure – exactly why kidney failure causes acute pericarditis is unclear
  • underactive thyroid gland (hypothyroidism) – exactly why hypothyroidism causes acute pericarditis is unclear
  • cancer – cancer that spreads from other parts of the body to the pericardium can damage tissue
  • heart attacks – pericarditis can sometimes develop after a heart attack, as damaged heart muscles can irritate the pericardium
  • injury or irritation to the tissue of the pericardium that occurs during heart surgery
  • severe injury to the chest – for example, following a car accident
  • some medications, such as penicillin or some chemotherapy medicines, have been known to trigger acute pericarditis as a side effect in some people

Recurring pericarditis

The cause of recurring pericarditis is still unknown.

One theory suggests that your immune system may be responsible. Your immune system reacts months or even years after the initial infection that caused acute pericarditis and attacks the heart, leading to inflammation of the pericardium.

Another theory suggests that fragments of the virus may lay inactive in the tissue of the pericardium and suddenly reactivate, triggering the process of inflammation.

People treated with steroids during their first episode of acute pericarditis are six times more likely to develop recurring pericarditis than people who don’t receive this treatment. Because of this, steroids are used as a last resort, if you fail to respond to other medications.

Read more about treating pericarditis.

Diagnosing pericarditis

Treating pericarditis

Pericarditis is usually treated with medication, although surgery is used in rare cases.

You will be assessed to see whether it’s safe for you to be treated at home.

You will usually be admitted to hospital if:

  • you have a high temperature (fever) of 38C (100.4F) or above
  • you have a high number of white blood cells – this could be the result of a serious infection
  • your symptoms develop after a sudden injury to your chest
  • you take blood-thinning medication (anticoagulants)
  • blood tests show you have high levels of a type of protein called troponin in your blood (this can be the result of damage to the heart muscle)
  • there is a risk of you developing cardiac tamponade, a serious complication of pericarditis caused by a build-up of fluid around the heart

You may also be admitted to hospital if treatment doesn’t work.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Most cases of pericarditis can be successfully treated with non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs work by reducing the inflammation of the pericardium, and also relieve the chest pain.

Ibuprofen is the preferred choice of NSAID. The exception is if you’ve recently had a heart attack, as ibuprofen can interfere with the healing of your heart. In such circumstances, high-dose aspirin will usually be recommended.

As NSAIDs can occasionally cause stomach ulcers, you will probably be prescribed an additional medication called a proton pump inhibitor that provides protection against stomach ulcers.

Colchicine

Colchicine is a medicine that can be used on its own or in combination with NSAIDs.

It’s often used if your symptoms fail to respond to NSAIDs or you are unable to take NSAIDs because of a pre-existing medical condition. 

Colchicine is useful because it can reduce inflammation of the pericardium by killing certain cells.

Side effects of colchicine include:

  • abdominal pain
  • vomiting
  • diarrhoea

These side effects usually improve once your body gets used to the medication.

Colchicine does not currently have a licence to be used to treat pericarditis in the UK. However, studies have shown that colchicine can be effective in treating pericarditis, so you may still be prescribed it if the benefits outweigh any potential risks.

Corticosteroids

Corticosteroids are usually only given when the symptoms of pericarditis fail to respond to NSAIDs and colchicine, or there is a build-up of fluid inside the pericardium, which could put the heart at risk.

Corticosteroids block the effects of the immune system, leading to a reduction in inflammation.

Corticosteroids are powerful medicines and can have a range of side effects, especially if used for a long period of time.

Side effects of corticosteroids include:

  • weight gain
  • mood swings
  • increased sweating

Other treatments

Treatment for pericarditis is different if it’s not caused by a viral infection. For example, if your pericarditis is caused by a bacterial infection, such as tuberculosis, antibiotics are used.

In some cases, the fluid that builds up around the heart may be drained with a needle during a procedure called pericardiocentesis. However, this is usually only used if you develop complications of pericarditis.

Recurring pericarditis

NSAIDs can be used to relieve symptoms of an episode of pericarditis, while a long-term course of colchicine has proved effective in preventing symptoms returning.

If symptoms persist, then a short-course of steroid medication may be recommended.

If your symptoms are particularly severe and not responding to medication, a type of surgery known as pericardiectomy may be recommended.

This involves the surgeon making a large incision in your chest and removing some or all of your pericardium.

A pericardiectomy is usually regarded as a last resort, as the surgery is relatively risky – there is an estimated 1 in 20 chance of it causing death.

Complications of pericarditis