What is Pericarditis? Causes, Symptoms, and Treatment Options

What is Pericarditis?

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The pericardium is a two-layered thin membrane that surrounds the heart. The inner layer of this membrane is attached to the heart muscle, while the outer layer is slightly looser. A small amount of fluid exists between the two layers, allowing the heart to contract and relax freely.

Pericarditis is inflammation of this membrane. As a result of inflammation, the pericardial layers swell, rub against each other, and cause characteristic chest pain. In some cases, more fluid than normal accumulates between the two layers (pericardial effusion), which can negatively affect the heart’s pumping function.

Why Pericarditis Matters

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Although pericarditis is generally a benign condition, it can lead to serious complications in some cases:

• Pericardial effusion: Fluid accumulation between heart membranes
• Cardiac tamponade: Accumulated fluid compressing the heart (emergency)
• Constrictive pericarditis: Thickening and stiffening of heart membrane in chronic cases
• Recurrence risk: Pericarditis may recur in 15-30% of patients

Types of Pericarditis

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Pericarditis is divided into different types based on duration and course:

1. Acute Pericarditis

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• Most common form
• Starts suddenly and usually resolves within 4-6 weeks
• Most commonly seen after viral infections
• Generally has good prognosis

2. Incessant Pericarditis

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• Lasts longer than 4-6 weeks but does not exceed 3 months
• Seen in treatment-resistant cases
• Requires closer follow-up

3. Recurrent Pericarditis

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• Reappears within 4-6 weeks after first episode resolves
• Seen in 15-30% of patients
• May recur for years in some patients
• Treatment may become more challenging

4. Chronic Pericarditis

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• Pericarditis lasting more than 3 months
• Rarely seen
• May be associated with underlying systemic disease

5. Constrictive Pericarditis

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• Thickening and stiffening of pericardium
• Restricts heart’s ability to expand
• Causes heart failure symptoms
• May require surgical treatment

Causes of Pericarditis

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Pericarditis has many different causes:

Infectious Causes

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Viral Infections (Most common):

• Coxsackie virus
• Echovirus
• Influenza virus
• COVID-19
• Epstein-Barr virus
• HIV

Bacterial Infections:

• Tuberculosis (significant in developing countries)
• Pneumococcus
• Staphylococcus
• Streptococcus

Other Infections:

• Fungal infections
• Parasitic infections

Non-Infectious Causes

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Autoimmune Diseases:

• Systemic lupus erythematosus (SLE)
• Rheumatoid arthritis
• Sjögren’s syndrome
• Scleroderma
• Vasculitis

Metabolic Causes:

• Uremia (kidney failure)
• Hypothyroidism (underactive thyroid)

Cardiac and Chest-Related:

• Post-heart attack (Dressler syndrome)
• Post-cardiac surgery (postoperative pericarditis)
• Cardiac catheterization complication
• Chest trauma

Other Causes:

• Cancer (lung, breast cancer metastases, lymphoma)
• Radiation therapy
• Certain medications (hydralazine, procainamide, isoniazid)
• Idiopathic (cause not found, in 80-90% of cases)

Symptoms of Pericarditis

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The most prominent symptom of pericarditis is chest pain, but other symptoms may also accompany:

Chest Pain Characteristics

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• Sharp and stabbing: Unlike heart attack pain, sharp in character
• Increases with breathing: Worsens with deep breathing
• Changes with position: Decreases when leaning forward, increases when lying on back
• Radiates to shoulder and back: May spread to left shoulder and back
• Increases with swallowing: Sometimes also increases with swallowing

Other Symptoms

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• Fever: Especially in infectious pericarditis
• Fatigue: General tiredness and malaise
• Cough: Dry cough
• Palpitations: Heart rhythm disorders
• Shortness of breath: If pericardial effusion is present

Serious Symptoms (Require Emergency Care)

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• Severe, sharp chest pain
• Serious shortness of breath
• Fainting or feeling like you might faint
• Signs of low blood pressure

Risk Factors

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Factors that increase the risk of developing pericarditis:

Infection and Immunity

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• Recent viral infection
• Use of immunosuppressive medications
• HIV infection
• Autoimmune disease diagnosis

Heart and Chest Related

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• Recent heart attack
• Post-cardiac surgery period
• Chest trauma
• Radiotherapy to chest area

Other Factors

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• Male gender (slightly more common)
• Young and middle age group
• Kidney failure
• Cancer history

Diagnostic Methods

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Pericarditis diagnosis is made through clinical evaluation and various tests:

Physical Examination

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• Pericardial friction rub: Characteristic “scratching” sound heard with stethoscope
• Most specific finding for diagnosis
• May not be heard in every patient
• Disappears with pericardial effusion

Electrocardiogram (ECG)

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An important test in pericarditis diagnosis:

• Stage I: Diffuse ST elevation and PR depression
• Stage II: Return of ST and PR to normal
• Stage III: Diffuse T wave inversion
• Stage IV: Return to normal ECG

Blood Tests

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• Inflammatory markers: Elevated CRP and sedimentation rate
• Cardiac enzymes: Troponin may be mildly elevated (myopericarditis)
• Complete blood count: Leukocytosis (elevated white blood cells)
• Kidney and thyroid function tests
• Autoimmune markers: When suspected

Echocardiography

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• Detection and amount of pericardial effusion
• Signs of cardiac tamponade
• Evaluation of heart function
• Findings of constrictive pericarditis

Chest X-ray

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• Enlargement of heart silhouette (in presence of effusion)
• Evaluation of lung pathologies
• Important when tuberculosis is suspected

Cardiac MRI and CT

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• Detection of pericardial thickening
• Evaluation of inflammation and fibrosis
• Helpful in constrictive pericarditis diagnosis
• Detection of tumors or other pathologies

Pericardiocentesis

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• Removal of pericardial fluid with needle
• Both diagnostic and therapeutic purposes
• Fluid analysis (infection, cancer investigation)
• Life-saving in tamponade treatment

Treatment Approaches

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Pericarditis treatment is planned according to the underlying cause and severity of disease:

1. General Measures

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• Physical activity restriction: Rest is recommended during acute phase
• Exercise should be limited until symptoms improve
• At least 3 months of exercise restriction for athletes
• Bed rest is usually not necessary

2. Medication Therapy

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First-Line Treatment:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Ibuprofen, aspirin, indomethacin

• Started at high doses for 1-2 weeks

• Dose is reduced when symptoms improve

• Stomach-protective medication given together

• Colchicine: Given together with NSAIDs

• Reduces recurrence rate by 50%

• Used for 3 months

• Also recommended for first episode treatment

Second-Line Treatment (In Resistant Cases):

• Corticosteroids: Prednisolone
• In those not responding to NSAIDs and colchicine
• In presence of autoimmune disease
• Slow dose tapering is important (should not be stopped suddenly)

Other Medications:

• Azathioprine, IVIG: In recurrent resistant cases
• Anakinra: IL-1 blockade, new treatment option
• Pain relievers: For symptom control

3. Treatment of Specific Cause

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• Antibiotics for bacterial infection
• Anti-tuberculosis treatment for tuberculosis
• Dialysis for uremic pericarditis
• Thyroid hormone replacement for hypothyroidism
• Oncological treatment for cancer-related pericarditis

4. Interventional and Surgical Treatment

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Pericardiocentesis:

• Treatment of cardiac tamponade
• Drainage of large effusions
• Obtaining fluid sample for diagnostic purposes

Pericardial Window:

• In recurrent effusions
• Creating an opening for continuous fluid drainage
• By surgical or percutaneous method

Pericardiectomy:

• Standard treatment in constrictive pericarditis
• Surgical removal of pericardium
• Is a high-risk operation

Complications

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Pericarditis may lead to complications in some cases:

Pericardial Effusion

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• Fluid accumulation between heart membranes
• Mild effusions usually do not cause symptoms
• Large effusions may cause shortness of breath
• Monitored with echocardiography

Cardiac Tamponade

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• Is an emergency!
• Accumulated fluid compresses the heart
• Heart’s pumping ability is impaired
• Low blood pressure, weak pulse, neck vein distension
• Requires emergency pericardiocentesis

Constrictive Pericarditis

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• Develops as a result of chronic inflammation
• Pericardium thickens and stiffens
• Heart cannot expand adequately
• Heart failure symptoms appear
• Surgical treatment (pericardiectomy) may be required

Lifestyle Recommendations

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Things to pay attention to during pericarditis treatment:

Rest and Activity

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• Reduce physical activity during acute phase
• Avoid intense exercise until symptoms pass
• 3 months of exercise restriction for athletes
• Return to activity gradually

Medication Use

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• Take your medications regularly and at full dose
• Do not neglect stomach-protective medications
• Do not stop treatment early even if symptoms improve
• Do not change medication dose without consulting your doctor

Follow-up

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• Attend regular cardiology check-ups
• Note changes in symptoms
• Recognize signs of recurrence
• Get follow-up ECG and echocardiography

Frequently Asked Questions (FAQ)

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When Should You See a Doctor?

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Seek medical help without delay in the following situations:

• Sharp chest pain that increases with breathing
• Chest pain accompanied by fever
• Shortness of breath
• Fainting or feeling like you might faint
• Rapid or irregular heartbeat
• Swelling in legs
• Recurrence of symptoms from previous pericarditis

Your chest pain complaint should be taken seriously, especially if you have recently had a viral infection or cardiac surgery. Early diagnosis and treatment are critically important to prevent complications.

If you have questions about pericarditis or would like to schedule an evaluation, please feel free to contact me.