ACUTE and CHRONIC PERICARDITIS: causes, symptoms, therapy of inflammation of the pericardium

What is pericarditis

There pericarditis a disease inflammatory of the pericardium, the thin membrane that surrounds the heart, and it can also be present without myocardial or endocardial involvement. Pericarditis can have bacterial or viral infectious causes, and can also arise in association or as a side effect of systemic pathological processes. Pericarditis often accompanies varying rates of pericardial effusion, and can cause symptoms such as shortness of breath, chest pain and fever. Therapy is based on the elimination of the triggering cause and on one anti-inflammatory therapy.

What is the pericardium

The pericardium it is a fibrous sac composed of two layers:

  • visceral pericardium, innermost, formed by a single layer of flattened mesothelial cells, collagen and elastin fibers adhering to the epicardial surface of the heart; it is supplied by the arterial branches of the coronary arteries and receives lymph from the vessels coming from theendocardium across the myocardium.
  • parietal fibrous pericardium, more external, with a thickness of about 2mm, consisting of an internal layer of flat cells and an external acellular layer, formed entirely of elastic fibers and collagen, which give it resistance and ability to adapt to changes in the volume of the heart. It is joined to adjacent intrathoracic structures through ligaments. It receives blood and lymphatic vessels from the mediastinum and is innervated by mediastinal fibers.

The two visceral and parietal layers continue in each other at the level of certain points of reflection, represented by the junction of the caval vessels with the right atrium and the oblique sinus (a J-shaped recess) for the left atrium .

Between the two layers of the pericardium there is one layer physiological of serous fluid, usually between 15 and 35 ml, there is often a slight pericardial detachment which is absolutely physiological.

The pericardium helps to maintain there position of the heart inside the thoracic cavity, since it is in continuity with the diaphragm, the sternum and the rest of the mediastinum through fibrous shoots, it acts in such a way as to reduce the friction during the cardiac cycle contributing to a normal expansion of the ventricles during the diastole and it is one barrier against infections and inflammations.
The pericardium also secretes prostaglandins which can modulate cardiac reflexes and coronary tone.

Diseases affecting the pericardium can occur in both acute and chronic forms. We can have: pericarditis (acute pericarditis, constrictive pericarditis, chronic pericarditis), pericardial effusion, cardiac tamponade. The most common is pericarditis, which is important to keep in mind in the differential diagnosis of chest pain.

Types of pericarditis

Pericarditis is therefore theinflammation of the pericardium and its serous, present even without myocardial or endocardial involvement, in association or as a side effect of systemic pathological processes, which is accompanied by variable rates of effusion.
The presence of effusion is not synonymous with pericarditis, even in healthy subjects can be identified effusions, of the transudative type, without clinical significance.
Pericarditis is characterized by the presence of an inflammatory state that determines the presence of exudate (inflammatory fluid) in the pericardial sac.

From the point of view of natural history, three main types of pericarditis are distinguished:

  • acute pericarditis: duration less than 6 weeks,
  • subacute pericarditis: duration between 6 weeks and 6 months and can be as much a transitional form between acute and chronic as a protracted variant of acute pericarditis,
  • chronic pericarditis: lasting more than 6 months, which is characterized as chronic pericarditis exudative and chronic pericarditis constricting.

Pericarditis can immediately manifest itself in an acute form, which then becomes chronic or directly as chronic pericarditis (in particular the form turberculous and secondary forms a systemic diseases or neoplastic). Rarely, acute pericarditis can be fulminant pericarditis and lead to patient death.

Causes of pericarditis

What are the causes of pericarditis? Based on the etiology of acute and chronic pericarditis we can classify it as:

  • idiopathic pericarditis (90%): from cause not well specified;
  • infectious pericarditis:
    • viral infection pericarditis: the most common but of which it is often difficult to identify the precise etiology. In cases where blood tests have been ascertained, the etiology has been seen to be involved Coxsackievirus, CMV, EBV, influenza virus, HIV. Chest pain has symptoms of the upper respiratory tract as prodrome with a 4-fold or more increase in antibody titer to support the diagnosis. Many cases are self-limiting; complications are infrequent and may include recurrent pericarditis, pericardial effusion, myopericarditis, tamponade, and constrictive pericarditis.
    • bacterial or mycobacterial pericarditis, the most common form of which is tuberculous pericarditis, with sneaky onset. Although uncommon, it must be borne in mind in patients with fever and pericardial effusion, particularly if a patient is immunocompromised. Pericardial involvement occurs in 1-2 % of pulmonary tuberculosis cases. If there is a high clinical suspicion, the patient should be hospitalized and initiated on triple therapy, while other diagnostic tests are done (BAAR - Alcohol Resistant Bacilli Investigation and pleural / pericardial biopsy).
      Other microorganisms and conditions involved are: Pneumococcus, Staphylococcus, Streptococcus, gram - septicemia, Neisseria meningiditis;
    • mycotic pericarditis from histoplasmosis, coccidioidomycosis, candidiasis, blastomycosis;
    • pericarditis from other infections caused by protozoa is parasites;
  • dry pericarditis: an acute form of pericarditis with absence of exudate;
  • uremic pericarditis (renal failure): increased levels of urea in the blood as a result of impaired renal excretion of the same in chronic renal failure, with high creatinine and elevated urea. It has a poor prognosis.
  • autoimmune pericarditis, associated with hypersensitivity or autoimmune diseases:
    • rheumatic disease, periarthritis nodosa (rare)
    • systemic connective tissue diseases: SLE (sitemic lupus erythematosus), rheumatoid arthritis, ankylosing spondylitis, scleroderma
    • from drugs: procainamide, anticoagulants, minoxidil
  • pericarditis post heart attack: this type of inflammation of the pericardium occurs 1-3 days after a transmural infarction, which affects the entire thickness of the ventricular wall and is thought to depend on the tissue trying to regenerate and making contact with the pericardium. These patients have an increased risk of congestive heart failure and mortality one year after heart attack. Fortunately, in recent years, thanks to the implementation of coronary angiography and angioplasty, this type of complication is much less frequent. Among the post-infarct pericarditis we remember:
    • Dressler's pericarditis or epistenocardial pericarditis,
      it usually occurs weeks or months after myocardial infarction, with an incidence of 1%. It presents as generalized malaise, fatigue and chest pain that could suggest a re-heart attack. It is usually associated with pyrexia and inflammation of other serous membranes such as the pleura and peritoneum.
      The cause of Dressler's syndrome is unclear, although its autoimmune nature has been proposed;
    • Postpericardiotomy syndrome, although it is very similar in presentation to Dressler's syndrome it usually occurs in the first 6-8 weeks after heart surgery. The incidence is between 10 and 40 %, believed to be caused by an autoimmune reaction.
  • purulent pericarditis: usually a complication of pneumonia or empyema caused by staphylococci, pneumococci, or other streptoccocci. An early diagnosis of pericarditis it is of primary importance, as it often leads to cardiac tamponade, associated with high mortality. Purulent pericarditis is characterized by the onset of fever, chills and dyspnoea lasting a few days. Chest pain or cardiac rubbing is not necessarily present.
  • neoplastic pericarditis: il pericardio appare coinvolto nel 5-10 %dei riscontri autoptici associati a neoplasie, principalmete polmonari, linfomi, della mammella, raramente neoplasie primitive.
  • pericarditis from radiation: actinic pericarditis appears 12 months to many years after the end of radiotherapy.

It is also important to mention pleuropericarditis, where you have pleura, the membrane that lines the lungs is inflamed and also the pericardium is inflamed, in fact viral inflammation or autoimmune diseases can often affect both serosa.

Acute pericarditis

The incidence of acute pericarditis in autopsy findings is between 2% and 6%, despite the prevalence of clinical diagnosis being 1: 1000 patients. Cases of pericarditis are more common in adults between the ages of 20 and 50, especially men.

The infectious pattern, which in this case is the most common, sees an invasion of the pericardial sac by pathogens that cause pericarditis with pericardial effusion and according to the different types of exudate we speak of:

- serous pericarditis: clear exudate, composed only of inflammatory cells, can undergo spontaneous resolution or evolve into fibrinous pericarditis;
- fibrinous pericarditis: exudate in the pericardial cavity rich in fibrin and little liquid, therefore due to the poao lubrication pericardial rubbing appears;
-haemorrhagic pericarditis: exudate composed of blood mixed with fibrin, with evolution towards a constricting form;
- purulent percarditis: yellow exudate, rich in pus from infections of pyogenic bacteria following trauma, surgery, sepsis, ...

Symptoms and clinical features

What are the main signs and symptoms of pericarditis?

  • Retrosternal pain or localized to the left of a piercing type, pleuritic-like (it is accentuated with breathing, with rotation of the trunk, with cough), with abrupt and sudden onset, it must be considered that the pericardium it is well innervated, any inflammation produces intense pain;
  • Typical radiation at the edge of the trapezius muscle, at the point of insertion on either side of the neck
  • The ache it is often attenuated by the sitting position with the torso tilted forward (genupectoral position and is accentuated in the supine position), characteristics that allow to exclude the heart attack whose pain does not change and disappears when nitroglycerin is administered;
  • Dyspnea: shortness of breath which usually results from pain, which restricts breathing. In the later stages, shortness of breath can be associated with the presence of pericardial effusion with initial cardiac tamponade and the development of heart failure ed respiratory failure.
  • among the symptoms of pericarditis the temperature (if> 38a probably bacterial pericarditis with purulent exudate), diffuse myalgias, hyperpyrexia, cough, sometimes hiccups, tachycardia and tachypnea. It is possible to detect in association a febrile episode or hyperpyrexia with shivering, a viral syndrome or a history of cancer or signs of autoimmune diseases (skin rashes), with the exception of the elderly who are often apyretic;
  • on physical examination: pericardial rubs, from friction of the two parietal and visceral sheets as a result of an inflammatory process and which unlike pleuritic rubbing do not disappear with inspiration

Pericarditis Diagnosis

First line exams

  • electrocardiogram in pericarditis: ECG may show diffuse ST-segment elevation usually in 3-4 peripheral and 4-5 precordial leads except avR and V1 concave upward. Unmodified QRS (DD with IMA) or with reduced voltage. Subsequently the ST returns to normal and the T's flatten out and become negative in the precordial ones; after a few weeks they normalize. Atrial artimias (atrial fibrillation or atrial extrasystoles) may appear.
  • Echocardiography in pericarditis: presence of pericardial effusion (> 100 ml) visible as an anechoic area between the posterior wall of the left ventricle and the underlying parietal pericardium. It is performed to assess the presence of pericardial effusion and any epicardial involvement.
  • Chest X-ray: cardiac shadow enlargement, sometimes with a "flask" appearance.
  • Exams of the blood: High ESR, high CRP.

Here is the echocardiogram of a patient with acute pericarditis where it is possible to see the collapse of the right ventricle and the pericardial effusion.

Second line exams

To identify other possible etiologies and in case of diagnostic uncertainty:

  • antinuclear antibody research (systemic lupus erythematosus),
  • HIV serology,
  • tuberculin skin test or Mantoux test
  • pericardiocentesis can be performed as a diagnostic procedure, where the sample is sent for microscopy, culture +/- for TB (if there is an indication) and cytology (in suspicion of malignancy) or as a therapeutic procedure in the presence of a major exudate or cardiac tamponade.

Pericarditis therapy

  • Hospitalization: necessary to determine the etiology.
    The patient should be monitored constantly by the cardiologist for any signs of cardiac tamponade, such as desaturation of oxygen in the blood detectable on pulse oximetry, swelling of the jugularis, changes in blood pressure, the presence of any effusion and the effectiveness of the treatment.
  • Important during the convalescence period the rest in bed, the less activities you do, the sooner you heal and avoid relapse problems.
  • As an anti-inflammatory medical therapy:
    • non-steroidal anti-inflammatory drugs (NSAID): Ibuprofen is the drug of choice. Indomethacin should be avoided in elderly patients. It is necessary to continue the therapy for 7 up to 14 days. A coverage with PPI (proton pump inhibitors) is required;
    • Colchicine: it can be used alone although it is often in combination with NSAIDs;
    • Aspirin: post-heart attack pericarditis had to be managed with ASA and colchicine, as NSAIDs may interact with the myocardial healing process;
    • Corticosteroids: cortisone is often used in case of pericarditis with autoimmune origin.

Prognosis

Times of healing of pericarditis:

  • patients with viral or idiopathic pericarditis recover within a few weeks, without any complications. However, there may be recurrent pericarditis, the causes of which have not yet been clarified and which can appear as persistent (appears shortly after drug therapy is interrupted) or intermittent (appears after months or years). Relapsing pericarditis can be treated with colchicine for another 6 months.
  • pericarditis post heart attack: remission in two weeks. There is a risk of relapse in 20-50 % of cases.
  • pericarditis associated with malignant disease, purulent effusion or tuberculosis. Mortality reaches 85 % in untreated tuberculous pericarditis.

Chronic pericarditis

As we said it is considered a complication of acute type pericarditis, there are two forms:

  • Exudative pericarditis: characterized by the production of abundant quantities of pericardial fluid: the pericardial effusion is its main characteristic. It often begins subtly and remains asymptomatic for a long time.
    Etiology: metastasis, tuberculosis, post-surgery, idiopathic.
  • Chronic constrictive pericarditis: where there is little or no heart effusion. It is the result of long-lasting inflammation. It is characterized by a fibrous thickening of the pericardium which leads to symptoms of right heart failure with peripheral edema, ascites and due to low cardiac output (from reduction of dilation in diastole): asthenia, dyspnoea (i.e. shortness of breath) due to exertion.
    Characteristic clinical signs: pericardial protodiastolic snap (Lyan), reduced pulse amplitude, reduced systolic blood pressure and normal diastolic values (pulse reduction), Kussmaul's sign (increased central pressure on inspiration, is also found in restrictive cardiomyopathy and right ventricular infarction)

Diagnosis and instrumental examinations

  • Echocardiogram or echocardium used for:
    • in constrictive pericarditis: pericardial thickening, reduction of diastolic expansion, "square root" sign (in end-systole the pressure falls and then rises to remain constant in diastole),
    • in exudative pericarditis: quantify pericardial effusion to exclude any cardiac tamponade,
  • ECG: QRS voltage reduction with flattening or inversion of the T in many leads;
  • Chest x-ray: Sometimes calcification in the cardiac shadow

Treatment of pericarditis

If cardiac tamponade is present it is necessary to proceed to percutaneous pericardiocentesis or  surgical pericardiotomy.
In case of constrictive pericarditis, a pericardiectomy preceded by cardiac catheterization.
Recall that in the case of cardiac tamponade there is usually the presence of Beck's triad with paraphonic heart tones (more attenuated), jugular venous distension and arterial hypotension.

Consequences of pericarditis

If the diagnosis is made in time the rates of survival after pericardial decortication they are 70 %, simple medical therapy is not enough.
Some patients improve immediately after the surgery, others due to the presence of myocardial atrophy take months to recover an optimal state of health.

 

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