What is the prognosis for pericarditis

Inflammation of the pericardium (pericarditis)


Under a pericarditis is one Inflammation of the pericardium to understand. The frequency of pericardial inflammation is underestimated as many pericarditis go undetected. At present, a frequency of around 1000 new cases per year per 1 million inhabitants is assumed in Germany.

What is pericarditis?

The connective tissue pericardium (pericardium: "surrounding the heart") is one sac-like covering of the heart. It consists of an inner sheet lying directly on the heart and an outer sheet which, as a capsule, surrounds, fixes and protects the heart in the chest. A narrow fluid border between the two leaves enables the heart to function with little friction.


The pericardium (top left) and its layers of tissue


Classification of pericarditis

Inflammations of the pericardium are subdivided into acute pericarditis, acutely recurring ("recurrent") and chronic pericarditis with possibly transition to scarred defect healing of the pericardium.

At a acute pericarditis an inflammatory process in the area of ​​the leaves of the pericardium leads to the exudation of inflammatory cells and inflammatory proteins. This type of inflammation is called fibrinous pericarditis. If, in the course of the inflammation, an increasing accumulation of fluid forms between the two leaves of the pericardium, this is called an acute exudative, serous, purulent or hemorrhagic form of pericarditis with pericardial effusion, depending on the findings. An inflammation of the pericardium can also involve the underlying heart muscle ("perimyocarditis").

All forms of pericarditis can heal or turn into an acutely recurrent or chronic form of pericarditis. A. Late complication Pericarditis is a scarred defect healing of the pericardium with calcium deposits and the resulting hindrance of filling of the heart. An armored heart ("pericarditis constrictiva") can develop as a pronounced form of these scarred changes.

What are the causes of pericarditis?

The cause of pericardial inflammation (pericarditis) can occur in isolation, but also in the context of a wide variety of underlying diseases. Over 50 percent of diagnosed pericarditis remain with no demonstrable cause ("Idiopathic"). If it is possible to name a cause, then stand infectious diseases, caused mainly by viruses, less often tuberculosis or other bacteria, in the foreground. Diseases of neighboring organs can also lead to an accompanying inflammatory reaction of the pericardium. This occurs mainly in the event of an acute heart attack, inflammation of the heart muscle ("myocarditis") or pneumonia.

Systemic inflammatory diseases can involve the pericardium. Pericarditis is less common with metabolic diseases, e.g. also with kidney failure. In the context of cancer, daughter tumors can form with a tumorous-inflammatory reaction of the pericardium. To other causes include cardiac surgery, radiotherapy in the chest, rheumatic diseases and rare systemic autoimmune diseases, HIV, parasites or certain drugs.

What are Pericarditis Symptoms?

The symptoms of pericarditis are depending on cause, intensity and course the disease. A typical symptom of acute pericarditis is a sometimes sharp pain that projects behind the breastbone and occasionally also radiates into the neck or shoulder region, which can intensify when inhaled and can vary depending on the body position. A lying body position can increase the pain, while sitting with the upper body bent forward can reduce the pain. General symptoms such as fever, sweating and decreased performance are mostly due to the underlying disease in which pericarditis occurs. Occasionally, these complaints are in the foreground, so that the pericardial disease is diagnosed only by chance as part of the accompanying examinations (e.g. heart ultrasound, EKG, chest x-ray).

The typical pericardial pain often occurs in the early stages of the disease. If a pericardial effusion develops over time, the symptoms can improve significantly or largely disappear. A particularly rapid increase in fluid in the pericardium can hinder the filling of the heart and thus lead to shortness of breath, circulatory problems and in some cases to circulatory failure ("pericardial tamponade"). An immediate relief puncture of the pericardial effusion is required here.

Acute-recurrent and chronic courses show one various clinical symptomswhich, among other things, depend on the form of the underlying disease and the disease activity, the subjective feeling of illness and the response to drug therapy.


How is pericarditis diagnosed?

There are many ways to track down pericarditis. The experienced doctor suspects the pericardial inflammation with typical symptoms. By means of a physical exam In the stage of fibrinous pericarditis, he can recognize a typical rubbing sound of the inflamed leaves of the pericardium with the stethoscope ("pericardial rubbing"). The character of the noise is compared to leather creaking synchronized with the heartbeat or the sound of footsteps on freshly fallen snow.

The electrocardiogram (EKG) can show typical changes depending on the stage of the disease. Usually the attending physician can differentiate the clinical picture from a heart attack with the help of the ECG results and the symptoms described.

Cardiac ultrasound (echocardiography)

A heart ultrasound reliably detects even small amounts of abnormal fluid in the pericardium. In addition, thickening of the leaves of the pericardium as well as deposits of inflammatory proteins can be detected. An amount of effusion in the pericardium can be documented without X-rays, monitored during the course and reliably interpreted with regard to its effect on cardiac function.


Cardiac ultrasound for pericardial effusion. The echocardiography proves the important pericardial effusion beyond any doubt

Chest x-ray

A. X-ray image is carried out with a view to, for example, a causative pneumonia and, in the case of a significant pericardial effusion, shows a typical so-called "buckskin-like" widening of the heart shadow.

Computed tomography (CT)

If there are difficulties with the echocardiographic assignment and localization of a pericardial effusion, computed tomography can be helpful. Pericardial effusions, which cannot be adequately represented by echocardiography, can also be precisely localized with regard to a puncture. A density measurement using computed tomography can help to further differentiate the character of the fluid, and the thickness of the pericardium can also be precisely determined.

In the case of advanced chronic inflammation, the CT scan is the method of choice to Calcifications in the pericardium to prove. This may be necessary with regard to an operative procedure in the presence of an armored heart. Questions about other causes of pericardial inflammation in the chest are reliably answered with the CT examination.


Cardiac MRI for pericardial effusion (arrows) in the context of fibrinous pericarditis

Magnetic resonance imaging of the heart ("cardio MRI")

Newer methods such as "cardiac MRI" may be required for further diagnostics. Cardio-MRI can answer the question of causal or accompanying myocardial inflammation with the highest informative value compared to other imaging methods. It detects the inflammatory reaction and thickening of the pericardium leaves and controls the progress of the therapy without exposure to x-rays. Furthermore, it guarantees a Tissue differentiation of the heart muscle and pericardium. Echocardiography, CT and cardio-MRI complement each other in terms of their informative value and can therefore be required together for optimal diagnosis.

Laboratory tests

Laboratory tests confirm that inflammatory reaction in the blood. Further examinations are carried out if necessary with regard to pathogen detection, tuberculosis screening and diagnostics in the event of suspected rare causative diseases (e.g. autoimmune diseases).

Other diagnostic procedures

Depending on the suspected diagnosis of the suspected underlying disease, further medical, e.g. endoscopic, imaging or surgical examinations with tissue removal may be required.

The Puncture of a pericardial effusionIt becomes therapeutically necessary in the case of pericardial tamponade. Larger symptomatic effusions (> 20 mm separation, measured before the contraction phase of the heart chambers) should also be punctured, also if tuberculous or purulent pericarditis is suspected. A puncture can also be performed on smaller effusions for diagnostic purposes if the effusion is unexplained or if a malignant effusion (i.e. caused by cancer cells) is suspected.

The subsequent laboratory, microbiological and cytological processing of the effusion leads to the causal diagnosis of pericarditis. A puncture should not be performed if the diagnosis can be made otherwise or if the effusion is too small and therefore cannot be punctured safely. Specialized centers have the option of one endoscopic examination of the pericardium ("pericardioscopy") with, if necessary, tissue removal from the pericardium for diagnostic purposes.

How is pericarditis treated?

Treatment of pericarditis is based on the cause of the pericarditis. Pain relievers are used in acute pericardial inflammation, preferably ibuprofen or diclofenac in conjunction with gastric protection agents.

Colchicine is used as an anti-inflammatory drug, alone or in combination with any of the above drugs. The duration of therapy is 3-6 months. Colchicine is used for recurrent, "recurrent" pericarditis and also increasingly for acute pericarditis, since recurrences can be reduced with colchicine.

Corticosteroids are given if the autoimmune disease is clearly diagnosed. However, untargeted use without a clear cause increases the recurrence rate. For example, if there is clear viral pericardial inflammation, corticosteroids must not be prescribed.

The treatment of chronic pericarditis corresponds to the treatment of acute pericarditis.

The specific therapy is based on the detailed diagnosis, possibly with the help of a pericardial puncture. Based on the results, specific, e.g. antiviral, antibacterial or immunosuppressive therapy can be initiated.

In the case of pericardial inflammation in the context of a certain underlying disease (e.g. cancer, kidney failure), the therapy is aimed at the causal disease. If necessary, a chemotherapeutic agent is instilled into the pericardium if it is infected with cancer cells. In the case of purulent pericarditis, the insertion of a suction drainage system is required.

An armored heart may undergo surgical therapy with fenestration, removal or partial removal of the scarred and calcified pericardial parts.


CT thorax in an armored heart with evidence of a calcareous shell surrounding the heart. In computed tomography, for methodological reasons, the calcification of the pericardium is shown brightly (arrows)

Risks and side effects of pericarditis therapy

Ibuprofen and diclofenac can prevent the occurrence of Favor stomach ulcers and are therefore prescribed in combination with gastric protection agents. The drugs mentioned should be prescribed with caution in cases of impaired kidney function.

Colchicine can typically be used too Gastrointestinal complaints result in nausea and diarrhea. These symptoms can be reduced by reducing the dose.

The side effects of any prescribed drug therapy, especially specific therapy in the case of a directly treatable cause, are considered and explained individually by the attending physician.

The patient is informed in detail by the attending physician about the risks of pericardial puncture (including bleeding, cardiac muscle or coronary artery damage, pleurisy, cardiac arrhythmia, emergency surgery).


What are the chances of recovery from pericarditis?

The prognosis is due to the variety of causes depending on the underlying disease. An accompanying pericarditis, e.g. in the case of pneumonia, on the one hand, can heal without consequences. On the other hand, a chronically relapsing course despite adequate therapy can pose a challenge for the attending physician.

Statistically, in around 30% of acute pericarditis, recurrent pericardial inflammation ("recurrence of pericarditis") is to be expected. Recurrent pericarditis has an approximately 50 percent chance of another recurrence.

Conclusion on pericarditis (pericarditis)

The diagnosis of pericarditis can be established, partly with the help of newer imaging methods such as cardiac MRI. Treatment of a diagnosed underlying disease often simultaneously treats the resulting pericarditis. If the pericardial effusion is unclear, purulent, tubercular, or malignant pericarditis is suspected, or if pericarditis is chronically recurrent, a pericardial puncture may be required. The specific therapy is based on the results of the differentiated analysis of the pericardial fluid and on the results of the environment diagnostics. The prospect of recovery depends on the ability to treat the respective causes.

In the case of chronic recurrent pericarditis and unclear treatment-resistant pericardial effusion, an experienced cardiological center should be consulted.

Author:
Dr. med. Matthias Wein