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Pericarditis proves a mysterious but usually manageable condition: inflammation of the heart's outer lining can be guided by imaging and often be managed by medication only.

Of all the conditions that can afflict the heart, pericarditis is among the most unpredictable and least-understood. But in many cases, it's a short-term, self-limited problem that can be cleared up with anti-inflammatory medications. Surgery may be needed to treat constrictive pericarditis.

Pericarditis is an inflammation of the pericardium, the thin, two-layered sac that surrounds the heart to help protect it from infection. Many circumstances can lead to pericarditis, ranging from a viral infection to a reaction to a heart attack or heart surgery to autoimmune diseases.

Allan Klein, MD, Director of Cardiovascular Imaging Research and Director of the Center for the Treatment and Diagnosis of Pericardial Diseases at Cleveland Clinic, says that in developed nations like the U.S., the cause of about 80 percent of pericarditis cases are idiopathic (unknown) in origin or viral. Often the cause isn't found.


"Pericarditis is an underreported condition," Dr. Klein says. "I think it's an increasing and not well-understood phenomenon."


He says that the reason for the rise in pericarditis cases is due, partly at least, to the increasing number of interventional procedures such as radio-frequency ablation, pacemaker insertion or cardiac surgery and other interventions that all require going through the pericardium to reach the heart. Even under the best conditions, any disturbance of the pericardium puts the lining at risk.

However, the value of these life-saving procedures far outweighs the risks of developing pericarditis.

Symptoms and diagnosis

The most indicative sign of pericarditis is a sharp chest pain that increases with breathing, particularly when lying down, that can be relieved by sitting up and leaning forward. Other symptoms include difficulty breathing, especially when lying down, a dry cough and pain in the back, neck or left shoulder. Pericarditis can often be diagnosed with an electrocardiogram (EKG) that shows changes in the patterns of your heart rhythm. The patterns are distinct from those that would reveal a heart attack on an EKG. But even before an EKG is ordered, your doctor may have a good idea that pericarditis is the problem when he listens to your heart and hears a "pericardial rub," a rubbing sound made by the inflamed pericardial linings.

One of the more recent breakthroughs in pericarditis diagnosis and treatment is the use of cardiac imaging. For example, an echocardiogram to show fluid around the heart (pericardial effusion) or a thickened lining around the heart (constrictive pericarditis). A cardiac MRI to assess the degree of inflammation can also be useful, Dr. Klein explains, to establish the extent of the problem at first and then to measure how the pericardium is responding to treatment over a period of time.

"If we see that the condition is improving, we can start tapering the medications, and if the pericardium is still inflamed after a few months, we know we need to make adjustments," he says. "We are trying to provide a systematic approach to treating pericarditis."

Treating pericarditis

Usually, the first attempt to treat pericarditis is with nonsteroidal, anti-inflammatory drugs (NSAIDs), such as large doses of ibuprofen three times daily. Another anti-inflammatory medication, known as colchicine, which is used to treat gout, may be prescribed for recurrences. If you're on high doses of NSAIDs for a long period of time, you may also be prescribed a proton pump inhibitor to prevent stomach problems and you will be checked to make sure the medications are not affecting kidney or liver function. Steroids, such as prednisone, may be needed for advanced inflammatory or resistant cases.

However, even if your pericarditis seems to have vanished, it may very well come back without warning. Dr. Klein says about 30 percent of pericarditis cases are recurrent, often after stopping the medications. "It's sort of like a curse," he says. "It won't do you in, but it will come back and you'll need medication to treat it."

He adds that one of the most frustrating aspects of treating pericardial disease is that there is no way of knowing if it will be recurrent. And for patients, to effectively treat pericarditis and help prevent recurrence, there will be a need to take medications even when they are feeling fine.

Types of pericarditis

Yet another aspect of pericarditis that makes it especially troubling to treat and suffer through as a patient is that it can appear in a variety of forms. And you don't always know how the condition will respond to treatment, whether it will worsen, disappear and come back or disappear for good.

The most common form is acute pericarditis, which develops suddenly and presents symptoms without warning. Dr. Klein says that with medications, acute pericarditis often disappears within a few months. If the condition lingers for more than three months after an acute attack, it is considered chronic pericarditis.

Other forms of the disease include infectious pericarditis, which is caused by a viral, bacterial, fungal or parasitic infection.

In addition to the usual antiinflammatory medications, antibiotics may be prescribed. Of the more serious types of pericarditis is constrictive pericarditis--in which the layers of the pericardium can become stiff, causing scars and interfering with the normal function of the heart.

Pericarditis can also lead to a build-up of fluid in the pericardium, a condition known as pericardial effusion, a serious development that can interfere with the heart's ability to pump efficiently. This may be treated by draining the fluid with the use of catheter guided by echocardiography or a pericardian window (pericardiotomy).
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Publication:Heart Advisor
Article Type:Disease/Disorder overview
Geographic Code:1USA
Date:Mar 1, 2010
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