Pericardial Disease – Causes, Symptoms & Treatment

What Is Pericardial Disease?

Pericardial disease is an umbrella term for all conditions affecting the pericardium -- the double-layered fibrous sac that surrounds and protects the heart. The pericardium anchors the heart within the chest cavity, prevents excessive cardiac distension, and facilitates smooth heart movement through a small amount of lubricating fluid between its layers.

Pericardial diseases can be acute or chronic, ranging from mild inflammation to life-threatening emergencies such as cardiac tamponade.

Types of Pericardial Disease

Pericarditis

Pericarditis is the most common form of pericardial disease. It refers to inflammation of the pericardium and can be classified as:

• Acute pericarditis: Inflammation lasting less than 4 to 6 weeks.
• Recurrent pericarditis: Repeated episodes of inflammation after a symptom-free interval.
• Chronic pericarditis: Persistent inflammation lasting more than 3 months.

Pericardial Effusion

A pericardial effusion is an abnormal accumulation of fluid within the pericardial sac. Small effusions may be asymptomatic, while larger ones can impair cardiac function.

Cardiac Tamponade

Cardiac tamponade is a medical emergency in which excessive fluid accumulation in the pericardial sac compresses the heart, severely reducing its ability to pump blood effectively.

Constrictive Pericarditis

Constrictive pericarditis occurs when chronic inflammation leads to scarring and stiffening of the pericardium. The rigid sac restricts the filling of the heart and can cause symptoms similar to heart failure.

Causes

Pericardial diseases can be triggered by a variety of factors:

• Infections: Most commonly viral (e.g., Coxsackievirus, influenza, SARS-CoV-2), but also bacterial (e.g., tuberculosis) or fungal.
• Autoimmune disorders: Systemic lupus erythematosus, rheumatoid arthritis, and Sjogren syndrome.
• Myocardial infarction: Post-infarction pericarditis (Dressler syndrome).
• Malignancy: Primary pericardial tumors or metastases from other cancers.
• Renal failure: Uremic pericarditis in advanced kidney disease.
• Trauma and surgery: Chest injuries or cardiac surgical procedures.
• Radiation therapy: Following treatment for chest or thoracic cancers.
• Idiopathic: In many cases, no specific cause is identified.

Symptoms

Symptoms vary depending on the type and severity of the pericardial disease. Common presentations include:

• Chest pain: Often sharp or stabbing, worsened by breathing in or lying flat, and relieved by leaning forward.
• Fever and general malaise in cases of infectious pericarditis.
• Shortness of breath: Particularly with pericardial effusion or constrictive pericarditis.
• Palpitations or irregular heartbeat.
• Dizziness, weakness, and low blood pressure in cardiac tamponade.
• Distended neck veins, leg swelling, and fatigue in constrictive pericarditis.

Diagnosis

Diagnosis of pericardial disease involves a combination of clinical assessment and diagnostic tests:

• Medical history and physical examination: Listening for the characteristic pericardial friction rub.
• ECG (Electrocardiogram): Typical changes associated with pericarditis.
• Echocardiography: Ultrasound imaging of the heart to detect effusions and assess cardiac function.
• Blood tests: Inflammatory markers (CRP, ESR), cardiac biomarkers (troponin), and kidney function tests.
• Cardiac MRI: Detailed imaging of pericardial changes and active inflammation.
• Chest CT scan: Detection of pericardial calcifications in constrictive pericarditis.

Treatment

Medical Therapy

Treatment is guided by the underlying cause and the type of pericardial disease:

• NSAIDs (Non-steroidal anti-inflammatory drugs): Ibuprofen or aspirin are first-line treatments for acute pericarditis to relieve pain and reduce inflammation.
• Colchicine: Often added to NSAID therapy to prevent recurrence of pericarditis.
• Corticosteroids: Used in severe cases or autoimmune-related pericarditis, though with caution due to a risk of promoting relapse.
• Antibiotics or antiviral agents: Prescribed when a specific infectious cause is identified.

Interventional and Surgical Treatment

• Pericardiocentesis: A needle procedure to drain excess fluid from the pericardial sac, used in significant effusion or cardiac tamponade.
• Pericardiectomy: Surgical removal of the scarred pericardium in cases of constrictive pericarditis.

General Measures

• Physical rest and avoidance of strenuous activity until full recovery.
• Regular cardiology follow-up appointments.

Prognosis

Most cases of acute pericarditis resolve completely with timely treatment. Recurrent or chronic forms and constrictive pericarditis require more intensive management and close monitoring. Cardiac tamponade is a life-threatening emergency requiring immediate medical intervention.

References

1. Adler, Y. et al. - 2015 ESC Guidelines for the Diagnosis and Management of Pericardial Diseases. European Heart Journal, 36(42), 2921-2964. European Society of Cardiology (ESC), 2015.
2. Imazio, M. et al. - Colchicine in Addition to Conventional Therapy for Acute Pericarditis. New England Journal of Medicine, 369, 1522-1528, 2013.
3. European Society of Cardiology (ESC) - Guidelines on Pericardial Diseases. www.escardio.org, accessed 2024.