Learn About Your Heart...
Made Simple


By Nicolas Shammas, MD


A new, comprehensive sourcebook for
heart and vascular disease patients

Cardiovascular Health Topics



1.
Statistics about Heart and Blood Vessel Diseases in the United States
2.
Structure and Function of the Heart and Blood Vessels
3.
Diseases of the Blood Vessels of the Heart
4.
Surgical Therapies for the Cardiovascular Patient
5.
Peripheral Vascular Disease
6.
Diseases of the Blood Vessels of the Head and Neck
7.
Strokes: How to Survive Them and How to Prevent Them
8.
Valvular Heart Disease
9.
Heart Rhythms: How to Recognize Them and Treat Them
10.
Congestive Heart Failure
11. Understanding Cardiomyopathy, or Weak Heart Muscle
12. Children and Heart Disease
13. Diseases of the Pericardium
14. Systemic Illnesses, Infections and Drugs that Affect the Heart
15. Erectile Dysfunction: a Vascular Disease
16. Cardiovascular Disease Prevention
17. Heart Healthy Nutritional Tips
18. Cardiac Rehabilitation
19. Medications for Cardiovascular Disorders
20. Heart Tests You Need to Know
21. Learn What to Do in a Medical Emergency
22. How to Choose Your Doctor and Hospital
23. Medical Research and How You Can Get Involved
24. Taking the Next Step — A Few Community Resources to Help You Live More Healthfully
25. How Much Did You Learn from This Book: Take a Simple Test

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Figure 1.

DISEASES OF THE PERICARDIUM

Edmund O. Fiksinski, MD, FACC

What is the pericardium?

The pericardium is a thin but strong fibrous sac that envelops the heart (see Figure 1). The pericardium is attached to a portion of the great blood vessels in the chest, the diaphragm, and the central breastbone. The space between the inner and outer layer of the pericardium is filled with a small amount of lubricating fluid. The amount of fluid that can be accommodated within the space is quite small, usually less than a third of a cup. The pericardium maintains an optimal position of the heart within the chest throughout the cycle of respirations, protects the heart from infections, and prevents sudden enlargement and stretching of the heart chambers.

What are the most common diseases affecting the pericardium?

By far, the most common process affecting the pericardium is pericarditis, an inflammation in the lining of the heart. Other diseases, including benign and malignant tumors, are much less frequent.

What is pericarditis and how is it caused?

Pericarditis is an inflammatory process involving both the inner and outer layers of the pericardium. It can be viewed as a reaction of the pericardium to a variety of different factors.

The most common cause of pericarditis is viral infection. Pericarditis can be a consequence of viral infection in children. Some of the viruses that cause pericarditis are the same viruses that cause common respiratory infections. A typical patient with acute pericarditis is a young man who recently suffered respiratory infection. Pericarditis is also seen among patients infected with HIV virus.

Bacterial infections involving the pericardium are infrequent and usually result from a source of infection elsewhere in the body. Pericarditis occasionally follows chest surgery.

In the past, tuberculosis was a common cause of pericarditis. Today, with effective anti-tuberculosis therapy widely available, tuberculosis pericarditis usually occurs in patients with weakened defense systems (for example, patients with cancer or HIV).

There are many other potential causes of pericarditis, including trauma, kidney failure, hypothyroidism (insufficient production of thyroid hormone), cancer (most frequently breast, lung, and blood), and some medications, including hydralazine, procainamide, isoniazid, reserpine, and methyldopa. Oral but not topical minoxidil has been reported to cause pericarditis. Radiation to the chest may also cause pericardial inflammation and is related to the dose duration as well as the quality of the technical equipment. It may occur during or following radiation therapy. Pericarditis is a possible complication of heart attack.

What are the symptoms of pericarditis?

The typical symptom of pericarditis is chest pain associated with fever and feeling sick. The pain is usually sharp, located in the center and the left side of the chest, often spreading to the neck and the left shoulder. The pain is made worse by deep breathing or swallowing. It is relieved with sitting. A dry cough, hiccups, and breathing difficulty may be present.

How is pericarditis diagnosed?

The diagnosis is established based on the characteristic pain and the presence of a typical crackling sound called pericardial rub, frequently compared to the sound of walking in the snow. An electrocardiogram, or ECG, is frequently abnormal and shows characteristic changes. Other laboratory tests may be helpful and frequently include blood counts, blood cultures, erythrocyte sedimentation rate (ESR), and C-reactive protein. Additional tests for pericarditis include chest x-ray, echocardiogram, and heart magnetic resonance imaging (MRI) or computed tomography (CT) scan.

How is pericarditis treated?

The treatment of pericarditis begins with identification of its etiology (that is, its cause). The usual case of pericarditis caused by a viral infection is treated with pain killers and medications designed to reduce inflammation, such as aspirin, ibuprofen, or indomethacin. Other medications and in some cases steroids may be required.

If you suspect pericarditis, it is extremely important to be seen by a health professional to have the diagnosis confirmed. Sometimes a heart attack may feel similar to pericarditis, and in such a case, any delay in therapy can have profound consequences. Pericarditis caused by other previously mentioned factors may require a different approach. For example, bacterial infection is treated with antibiotics and surgical drainage.

What are some of the complications of pericarditis?

The most common complication of pericarditis is tamponade, an excessive accumulation of fluid between the 2 layers of the pericardium, leading to compression and impaired function of the pumping heart chamber. It can be life threatening and requires immediate attention. The treatment in this case is pericardiocentesis, which involves drainage of the pericardial fluid with a needle. Surgical drainage may be required in cases where needle aspiration is ineffective.

How is pericardiocentesis performed?

Pericardiocentesis, or pericardial tap, is frequently performed in the patient's room at the bedside or in a specialized procedure room called the cardiac catheterization laboratory. The area below the breastbone is cleaned with an antiseptic solution, and a local anesthetic agent is administered. Intravenous sedation is often given to improve the patient's cooperation. A needle is then introduced just below the breastbone under the guidance of an ECG or an echocardiogram utilizing sound waves to visualize the heart structures. Once the needle is within the pericardial space, a guide wire is placed through the needle, and the needle is then exchanged for a plastic catheter. This catheter is then connected to a container that will collect the fluid.

The catheter is often left within the pericardium for several hours and sometimes even a few days. The needle passage into the pericardium may provoke a feeling of pressure. Less frequently, the patient experiences transient pain, which may require additional pain medication.

Complications of this procedure may include bleeding, penetrating trauma to 1 of the heart chambers, irregular heart rhythm, puncture of the surrounding organs, and infection. Fortunately, these complications rarely occur. However, when present, they may require surgical correction.

Can pericarditis cause long-term problems?

The most common long-term complication of pericarditis is constrictive pericarditis, which occurs when the inflammation within the pericardial sac leads to scarring of the 2 layers of the pericardium and turns them into a stiff, leather-like case. This limits the heart's ability to fill up with blood and leads to symptoms of progressive shortness of breath, weakness, and leg swelling. Constrictive pericarditis is treated with surgical removal of the pericardium.

What is the prognosis in a typical case of pericarditis?

Many cases of pericarditis resolve (that is, heal) spontaneously or with treatment involving common anti-inflammatory medications. Most patients improve within a few weeks. In some people, the disease recurs within months to a year, sometimes repeatedly. The treatment is usually similar to the original therapy. Another medication used for recurrent cases is colchicine.

Surgical creation of an opening within the pericardium (pericardial window) is occasionally required and allows for free drainage absorption of the fluid.

What kinds of tumors can affect the pericardium?

The pericardium may be affected by benign and malignant tumors; however, these conditions are uncommon. On occasion, a cyst may develop within the pericardium and is usually found in middle-aged men and women. Some patients may present with symptoms of chest discomfort, shortness of breath, or heart rhythm irregularities. Diagnosis is typically confirmed with an echocardiogram, MRI, or CAT scan. Treatment requires surgical resection, although some cases of successful needle aspirations have been reported as well. A malignant tumor of the pericardium is called mesothelioma. This rare tumor is linked to long-term asbestos exposure. It usually takes over 15 years for this form of cancer to occur, and in its early stages, it can be easily missed. Symptoms, such as chest pain, cough, and shortness of breath, can be frequently misleading. A diagnosis is often suggested by a CAT scan or MRI but is frequently made in the late stages of the disease. Since mesothelioma is among the most aggressive cancers, the treatment is often ineffective and is usually aimed at the relief of symptoms. Chemotherapy or radiation therapy is sometimes used. New treatments are currently being studied and may become available in the next several years.

What is the most important thing to remember about pericardial disease?

Do not try to self-diagnose yourself with pericarditis. Do not use aspirin or other anti-inflammatory medications for chest discomfort. It is extremely important for any person with chest pain to seek immediate professional attention. Remember, in the United States, heart attack is still the number 1 killer.


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