What are the causes and symptoms of pericardial disease (inflammation of the pericardium)?

From the Guidelines

Pericardial disease is primarily caused by inflammation of the pericardium, which can be due to various factors such as immune conditions, infections, or trauma, and its symptoms include chest pain, orthopnoea, cough, and dysphagia, with treatment depending on the underlying cause and severity of the condition. The causes of pericardial disease can be categorized into several groups, including:

• Immune conditions such as lupus, serum sickness, polyserositis, and autoimmune diseases
• Infections such as bacterial, viral, or fungal infections
• Trauma, including physical injury or surgical procedures
• Neoplastic diseases, including primary or secondary tumors
• Other causes, including radiation, medications, or genetic disorders

Symptoms of pericardial disease may include:

• Chest pain, which can be sharp or dull and may radiate to the arms or neck
• Orthopnoea, or shortness of breath when lying down
• Cough, which can be dry or productive
• Dysphagia, or difficulty swallowing
• Fatigue, or feeling weak or tired
• Fever, which can be low-grade or high-grade

Diagnosis of pericardial disease typically involves a combination of physical examination, laboratory tests, and imaging studies, including:

• ECG, which can show changes in the heart's electrical activity
• Echocardiography, which can show the size and function of the heart
• Chest X-ray, which can show the size and shape of the heart
• CT or MRI scans, which can show the pericardium and surrounding tissues
• Blood tests, which can show signs of inflammation or infection

Treatment of pericardial disease depends on the underlying cause and severity of the condition, and may include:

• Medications, such as NSAIDs, colchicine, or corticosteroids, to reduce inflammation and relieve symptoms
• Pericardiocentesis, or removal of fluid from the pericardial space, to relieve tamponade or diagnose the cause of the disease
• Pericardiectomy, or surgical removal of the pericardium, to treat constrictive pericarditis or other conditions
• Treatment of underlying conditions, such as infections or autoimmune diseases, to prevent recurrence of pericardial disease, as recommended by the European Society of Cardiology guidelines 1.

Key points to consider in the management of pericardial disease include:

• Diagnosing the underlying cause of the disease to guide treatment
• Monitoring for complications, such as cardiac tamponade or recurrent pericarditis
• Treating underlying conditions to prevent recurrence of pericardial disease
• Using a combination of medications and procedures to relieve symptoms and improve outcomes, as supported by the highest quality evidence available 1.

From the Research

Causes of Pericardial Disease

• Idiopathic or viral pericarditis is the most common cause in North America and Western Europe 2
• Tuberculosis is the most common cause in endemic areas 2
• Pericarditis can also occur after cardiac procedures or operations 3, 2
• Other causes include autoimmune diseases, postpericardiotomy syndromes, and trauma 4, 5

Symptoms of Pericardial Disease

• Sharp, pleuritic chest pain that worsens when supine (≈90%) 2
• New widespread electrocardiographic ST-segment elevation and PR depression (≈25%-50%) 2
• A new or increased pericardial effusion that is most often small (≈60%) 2
• Pericardial friction rub (<30%) 2
• Fever, subacute onset, and large effusion/tamponade are high-risk features indicating hospitalization 5

Diagnosis of Pericardial Disease

• Diagnosis is based on the presence of 2 or more of the following: chest pain, electrocardiographic changes, pericardial effusion, and pericardial friction rub 2
• Echocardiography, computerized tomography, magnetic resonance imaging, and hemodynamics can be used to diagnose constrictive pericarditis 5, 6
• Pericardiocentesis and pericardial/epicardial biopsy may be necessary to clarify the etiology of pericarditis 5

Treatment of Pericardial Disease

• Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line therapy for uncomplicated acute pericarditis 4, 3, 2
• Colchicine can be used concomitantly with NSAIDs as the first-line approach, particularly in severely symptomatic cases 3, 2
• Corticosteroids can be used in refractory cases or in those with immune-mediated etiologies, although they should be avoided due to a higher risk of recurrence 4, 3, 5
• Pericardiectomy is the only treatment for permanent constrictive pericarditis and may be necessary for recurrent cases 5, 6