Achy Breaky Heart

 Achy Breaky Heart

By Peter Galvin, MD

In North America and Europe, pericarditis accounts for up to 5% of ER visits for chest pain that is not due to a heart attack. Pericarditis is inflammation of the sac surrounding the heart (pericardium) that causes chest pain. The cause of pericarditis is often unknown, or it can develop following a viral infection, heart attack, cardiac procedure such as catheterization or pacemaker placement, or cardiac surgery. Less often, it may occur in patients who have cancer, radiation therapy, bacterial infection, chronic kidney failure, or an autoimmune disease. In some parts of the world, tuberculosis is the most common cause.

Patients with pericarditis typically have sharp chest pain that worsens with deep breathing (pleuritic chest pain), coughing, or lying on their back. They may also experience shortness of breath, fatigue, fever, persistent cough, irregular heartbeat, weight loss, or night sweats. Rarely, patients with a large amount of fluid in the pericardial sac (pericardial effusion) may develop low blood pressure due to compression of the heart, which decreases its ability to pump blood. This condition, known as cardiac tamponade, requires immediate drainage of the pericardial effusion to avoid development of shock and death.

Acute pericarditis is diagnosed in those who meet two of four criteria: sharp chest pain that increases when lying down, certain abnormal EKG findings, pericardial effusion (can be seen by chest X ray or ultrasound [echocardiogram]), or a specific high-pitched heart sound best heard with a stethoscope when the patient leans forward. Patients with pericarditis often have elevated markers of inflammation in their blood, for example C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). In those with a known cause of pericarditis, that cause needs to be treated. This includes tuberculosis and chronic renal failure (CRF). The development of pericarditis in CRF is an indication that dialysis needs to be started. In those whose pericarditis has no known cause or may be related to a viral illness, high-dose NSAIDs (i.e., ibuprofen, naproxen) are typically used for pain relief and reduction of inflammation. The NSAID dosage can be reduced as the pain resolves. For those who cannot take NSAIDs, colchicine (an anti-inflammatory drug used to treat gout) can be used. Corticosteroids (prednisone) can be used if NSAIDs and colchicine are both contra-indicated.

About 15 to 30% of those with pericarditis will develop recurrent episodes of it. The risk of recurrent episodes is higher in those with autoimmune diseases, those with elevated levels of inflammatory markers in their blood, and those with higher levels of pericardial inflammation as seen on cardiac MRI. Otherwise, a first episode of acute pericarditis usually resolves although the patient should continue taking NSAIDs or colchicine for six months. For those whose symptoms persist or recur, oral steroids may be required, although for certain patients, non-steroidal inflammatory blockers such as rilonacept or anakinra may be preferable as they do not have steroidal side effects. Rarely, multiple recurrent episodes of pericarditis may persist for several years or longer.

For more information go to the website of the American Heart Association at www.heart.org

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