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Overview |
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Definition |
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Pericarditis encompasses all the numerous disorders of the pericardium. The
pericarditis disease processes fall into three categories:
- Acute pericarditis: inflammation of the pericardium (sometimes with
effusion) with numerous etiologies
- Pericardial effusion or pericardial tamponade: increased
intrapericardial pressure from effusion of the pericardia causing hemodynamic
compromise
- Constrictive pericarditis or chronic pericardial disease: pericardium
thickening and fibrosis, usually resulting from chronic inflammation
Pericardial effusion and constrictive pericarditis can occur together
(effusive-constrictive pericarditis). The condition is common in adolescents and
young adults, with males affected more than females. Pericarditis and
pericardial effusion are common manifestations of AIDS. Pericarditis is common
in end-stage renal failure. |
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Etiology |
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Acute pericarditis and pericardial effusion are idiopathic, or
include:
- Viral—coxsackie, echo, adenovirus,
Epstein–Barr, measles, mumps, influenza, infectious
mononucleosis, poliomyelitis, varicella, hepatitis B, cytomegalovirus
- Bacterial—haemophilus (notably children),
staphylococcus, streptococcus, pneumococcus, salmonella, meningococcus, Lyme
disease, legionella, mycoplasma
- Fungal—candida, histoplasmosis, Aspergillus,
Nocardia
- Parasitic—protozoal
- Drug-induced—procainamide, hydralazine,
anticoagulant, nicotinic acid, bleomycin, phenytoin, minoxidil, mesalamine
- Neoplastic (especially common in patients older than
50)—breast, lung, lymphoma, leukemia, melanoma,
mesothelioma
- Mycobacterium tuberculosis
- Connective tissue disease—systemic lupus
erythematosus, rheumatoid arthritis, rheumatic fever, scleroderma, polyarteritis
(nodosa), acute rheumatic fever
- Acquired immunodeficiency syndrome (AIDS)
- Cardiac trauma or rupture
- Metabolic disease—hemodialysis, uremia,
myxedema, cholesterol pericarditis, chylopericardium
- Radiation
- Myocardial infarction
- Dressler's syndrome
- Aortic dissection
- Sarcoidosis
- Pancreatitis
- Inflammatory bowel disease
- Amyloidosis
Constrictive pericarditis results from pericardial thickening and fibrosis,
either long after acute bacterial, fungal, viral, neoplastic, or uremic
pericarditis or from chronic inflammation. |
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Risk Factors |
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- Chest trauma
- Exposure to viral, bacterial, fungal, or parasitic
pathogens
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Signs and Symptoms |
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Acute pericarditis:
- Chest pain (often sudden, usually sharp, generally retrosternal with
radiation to the trapezial ridge)
- Pain intensified by lying down, coughing, and deep breathing, eased
by sitting up and leaning forward
- Breathing splinted
- Fever, malaise, flushing
- Myalgia
- Odynophagia
- Anorexia
- Anxiety
Pericardial effusion:
- Dyspnea
- Cyanosis
- Relative hypotension
- Tachycardia
- Altering consciousness
Constrictive pericarditis:
- Dyspnea
- Distension of jugular veins
- Peripheral edema
- Pulmonary congestion
- Fatigue
- Abdominal swelling
- Acute myocardial infarction
- Pneumonia
- Pulmonary emboli
- Aortic dissection
- Pneumothorax
- Cholecystitis
- Pancreatitis
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Diagnosis |
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Physical Examination |
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See Signs and Symptoms |
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Laboratory Tests |
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Acute pericarditis:
- Blood count and cultures
- Viral and fungal serologies
- Antistreptolysin-O (ASO) titer
- Cold agglutinins
- Heterophile test
- Thyroid function test
- Blood urea nitrogen (BUN)
- Creatinine
- Connective tissue disease screens
- Pericardial effusion: pericardial fluid analysis
- Will see leukocytosis with increased erythrocyte sedimentation rate
(ESR)
- Possible elevated creatine kinase (CK)
- Possible elevated lactate dehydrogenase (LDH)
- Possible elevated serum glutamic-oxaloacetic (SGOT)
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Pathology/Pathophysiology |
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- Acute inflammation of
pericardium
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Imaging |
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- Chest X ray: small pleural effusion with transient infiltrates
- Chest CT scan or MRI: calcified or thickened
pericardium
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Other Diagnostic
Procedures |
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If pericardial effusion is suspected, explore the patient history for viral
and flulike illnesses, trauma, and chronic hemodialysis.
- Electrocardiogram
- Echocardiogram
- Right heart catheterization
- Pericardiocentesis
- Pericardial biopsy
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Treatment Options |
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Treatment Strategy |
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Outpatient treatment is possible, but hospitalization is often appropriate
until the etiology or possible complications are known, to rule out myocardial
infarction and to watch for cardiac tamponade. Patients with acute significant
pericardial effusion should be hospitalized. |
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Drug Therapies |
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For idiopathic causes, aspirin and nonsteroidal anti-inflammatory therapy are
generally suitable. Corticosteroids may be prescribed for short-term use. Avoid
anticoagulants (hemopericardium risk).
- Aspirin—650 mg every four hours for two
weeks; standard contraindications, precautions, and interactions
- Ibuprofen—400 to 600 mg every six hours for
two weeks
- Indomethacin—25 to 50 mg every six to eight
hours for two weeks
- Colchicine—0.6 to 1.2 mg/day
- Azathioprine, prednisone—60 mg/day for two
to three days (if other drugs are ineffective)
Surgery may be needed for purulent pericarditis, uremia, and neoplasm
etiologies, ineffective drug therapy, chronic acute pericarditis. Pericardial
drainage may be needed with cardiac tamponade and hypotension.
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Complementary and Alternative
Therapies |
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Alternative therapies may have benefit as supportive treatments for some of
the causes of pericarditis. Homeopathics could be tried in addition to drug
therapies. The relief from symptoms can be quite dramatic. |
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Nutrition |
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- Vitamin C (1,000 mg tid) may help stabilize mast cells and decrease
inflammation. It also aids in fighting infection, and is an antioxidant. Vitamin
C is depleted in infections and inflammatory conditions.
- Coenzyme Q10 (50 mg bid) is an important antioxidant; it may help
prevent heart muscle damage and speed recovery.
- Consider sodium restriction for patients with constrictive
pericarditis.
- If pericarditis is of viral origin supplement with vitamin A (300,000
IU/day for 3 days).
- Flaxseed oil (3 g bid) decreases inflammation of
pericardium.
- Avoid saturated fats, alcohol, and sugars, which can lead to
increased inflammation and lowered immune function.
- Consume at least 5 servings of fruits and vegetables per day. These
foods are anti-inflammatory and protect the
heart.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
- Hawthorn (Crataegus monogyna) decreases capillary permeability,
stabilizes collagen, antioxidant, increases cardiac contractility,
anti-atherosclerotic, antihypertensive (mild ACE inhibitor) with very low
toxicity. Dose is 60 drops tincture tid, 1 tsp. berries steeped for 10 minutes
in hot water, or 100 to 250 mg tid as a supplement.
- Linden (Tilia cordata) is used for hypertension with nervous tension,
may be useful adjunctive treatment where there is anxiety. Dose is 1 tsp. dried
blossoms/cup hot water tid or 60 drops tincture tid.
- Blue monkshood (Aconitum napellus) has been described as an herbal
remedy for pericarditis without significant effusion. CAUTION: As this herb can
be highly toxic, even fatal, it is not recommended unless prescribed by an
experienced health care provider.
- If pericarditis is of viral origin recommend echinacea 500 mg or 60
drops of tincture 6 to 8 times per day.
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Aconite for sudden, sharp pains accompanied by anxiety (especially
fear of dying) and restlessness
- Spongia tosta for the sensation that the chest will explode, anxiety,
faintness, sweating; patient may be flushed
- Cactus grandiflorus for the feeling that there is a band around the
chest or a great weight on the chest; palpitations; feels better in the open air
and worse at night
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Acupuncture |
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Can be very helpful in decreasing inflammation, enhancing immune response,
and regulating cardiac function. |
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Patient Monitoring |
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Re-evaluate symptoms and cardiac status in two weeks. Consider follow-up
chest X ray and electrocardiogram after four weeks. Follow-up advised with
recurrence of symptoms. |
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Other
Considerations |
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Prevention |
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If patient is overweight, weight loss is recommended. |
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Complications/Sequelae |
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- Pericardial tamponade
- Noncompressive effusion
- Right-sided heart failure
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Prognosis |
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Course depends on cause and complications, although pericarditis generally is
self-limiting, and symptoms and inflammation resolve in two to four weeks. A
small percentage of acute pericarditis patients experience recurrence within
months. Constrictive pericarditis is gradually progressive.
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References |
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Andreoli TE, Bennett JC, Carpenter CCJ. Cecil Essentials of Medicine. 3rd ed.
Philadelphia, Pa: WB Saunders Co; 1993:110-114.
Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md:
Lippincott Williams & Wilkins; 1999:792-793.
Gruenwald J, Brendler T, Jaenicke C, eds. PDR for Herbal Medicines. Montvale,
NJ: Medical Economics Co; 1998:606-608.
Stein JK, ed. Internal Medicine. 4th ed. St. Louis, Mo: Mosby-Year Book;
1994:248-252.
Stoller JK, Ahmad M, Longworth DL, eds. The Cleveland Clinic Intensive Review
of Internal Medicine. Baltimore, Md: Williams & Wilkins;
1998:759-760. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |