Pericarditis: water around the heart, is it serious?

Pericarditis corresponds to inflammation of the pericardium, the covering of the heart. “The pericardium surrounds the heart. It is composed of two layers (a parietal layer which is exterior and a visceral layer which is interior). And within the pericardial space, there is lubricating fluid that surrounds the heart and allows it to contract and move without being felt. In the event of inflammation of the pericardium, the layers can no longer slide against each other without friction, which can cause pain. It’s a bit like rubbing two pieces of leather together: they stick“, describes Dr Delesalle. Pericarditis most often comes from an inflammatory mechanism, a reaction to a viral infection.

There are several types of pericarditis:

► acute pericarditis : it occurs suddenly and lasts a short time (a few weeks)

► chronic pericardity : it lasts more than 3 months. Generally, it results from tuberculosis or follows radiotherapy (to the left breast, particularly in breast cancer) or heart surgery.To operate on the heart, it is opened and there may be an inflammatory reaction distant from the operation which will become chronic and which will lead to constriction of the pericardium: the envelope is no longer very flexible, becomes rigid or more thick, which will constrain the heart which will have less space for its mobility. In this case, we speak of chronic constrictive pericarditis” explains Dr. Delesalle. Before adding: “In the case of chronic pericarditis, the inflammation lasts longer than in acute pericarditis, which can lead to fibrous remodeling of the pericardium, including calcifications.

► pericarditis which comes from an effusion “in other words, of a excess fluid in the pericardial cavity“, specifies our cardiologist. We speak of pericardial effusion to characterize the accumulation of fluid around the heart.

Diagram of pericarditis with effusion

► dry pericarditis when there is no excess fluid in the pericardial cavity, as opposed to pericarditis with effusion. “Be careful not to wrongly diagnose dry pericarditis, as some effusions may be invisible on cardiac ultrasound.” would like to clarify our interlocutor.

► idiopathic pericarditis when we do not know its cause.

What are the causes of pericarditis?

• A viral infection (mild ENT infection: cold, sore throat, laryngitis, rarely Covid, etc.).
• A bacterial infection.
• A lung infection.
• Cancer.
• Radiotherapy rays.
• Tuberculosis (chronic pericarditis).
• Autoimmune diseases (systemic (or systemic) lupus erythematosus, rheumatoid (poly)arthritis, rheumatic fever, etc.).
• Renal failure.
• A heart attack (late form of pericarditis).
• Cardiac surgery (pericarditis due to bloodshed).

Certain viruses can be responsible for pericarditis such as:

• Enterovirus (coxsackie)
• Herpes (cytomegalovirus, Epstein-Barr virus, human herpes virus-6)
• Adenovirus
• Parvovirus B19
• Sars-CoV-2 (it’s rare)

What are the symptoms of pericarditis?

Pericarditis can be symptomatic or asymptomatic (without symptoms). “Generally, viral pericarditis in a young person causes chest pain. But pericarditis can also be detected incidentally following examinations carried out in the context of cancer or another pathology (liver cirrhosis, digestive pathology, etc.) without the patient observing any particular pain.“, explains Dr Delesalle. In the case of symptomatic pericarditis, we can observe a fever, difficulty breathing, palpitations, shortness of breath, cough, etc.

The typical pain of pericarditis is “oppressive chest pain, near the heart (but not always), increased when lying down and when inhaling” describes our specialist.

“Faced with a suspicion of pericarditis, the greatest difficulty is to confirm the diagnosis in order to implement appropriate treatment.“, warns our interlocutor. For this, we base ourselves on several criteria:

• A bundle of clinical arguments: the type of pain felt, the presence of fever.
• Listening to the heart by auscultation using a stethoscope (a very particular friction noise can alert the doctor).
• Specific signs on the electrocardiogram.
• The appearance of the heart on cardiac ultrasound (pericardial effusion, etc.).
• The results of the blood test (elevation of inflammation biomarkers).
• Proof of pericardial inflammation by an imaging technique (CT, MRI).
• The results of a chest x-ray.

Treatment depends on the type and origin of pericarditis:

► Faced with viral pericarditis in a young and healthy subjectthe treatment consists of the prescription of anti-inflammatories: aspirin (administered for a few weeks, decreasing dosage schedule with different levels) and colchicine (administered long-term, for two to three months in order to limit the risk of recurrence of pericarditis). In addition to anti-inflammatories, painkillers can also be administered such as paracetamol. “If there is an effusion, we redo an ultrasound check during anti-inflammatory treatment and afterwards to ensure that the effusion regresses. We do a blood test to check that the inflammation is regressing and consider stopping the anti-inflammatories.“, explains the cardiologist.

► Faced with tuberculous pericarditistuberculosis must be treated.

► Facing pericarditis of bacterial origintreatment will consist of taking antibiotics

► Facing pericarditis with effusionin a patient treated for cancer, this will possibly be colchicine, chemotherapy or even a surgical puncture of the pericardium.

What are the possible complications of pericarditis?

Among the possible complications of pericarditis:

► Myocarditisinflammation of the heart muscle associated with a risk of cardiac arrhythmia and cardiac arrest

► Recurrence of pericarditis (we are talking about a incessant or intermittent pericarditis). In this case, we may need to carry out more in-depth examinations, in particular more sophisticated viral serologies to detect the virus in question, as well as a cardiac MRI.

► Cardiac tamponade is the complication of pericardial effusion. “In this case, the cardiac envelope (therefore the pericardium) fills with liquid so much that the liquid will compress the heart, which is no longer able to fill with blood at each cardiac cycle, therefore the heart s speeds up, blood pressure drops, there may be edema in the legs and this can lead to cardiac arrest“, explains Dr. Delesalle.

“Pericarditis is an inflammation of the pericardium which causes pain, therefore a symptom that should be treated, but it is not serious in itself. On the other hand, myocarditis is an inflammation of the heart muscle which is associated with a risk of cardiac arrhythmia (heart rhythm disorder) and therefore cardiac arrest. So if there is pericarditis with myocarditis, we will prioritize the management of the myocarditis“, insists Dr. Delesalle. The way to distinguish them is to do an assay for troponin, which is a cardiac enzyme.

► Elevated troponin: sign of inflammation of the heart muscle, we are moving more towards a myocarditis.

► Normal troponin: sign of inflammation of the cardiac membrane, we are moving more towards a pericarditis.

Is pericarditis fatal?

“In general no, our interlocutor immediately responds. However, it is interesting to make a diagnosis quickly enough to implement appropriate treatment. There is, however, a first problem: the clinical symptoms and ECG signs are variable and depend on the position of the leaflets. Likewise, the friction on auscultation can be heard at one time and no longer be heard 5 minutes later, which complicates the diagnosis. Diagnosing pericarditis also and above all allows a blood test to rule out the diagnosis of associated myocarditis, which can be fatal.”

How much downtime for pericarditis?

Generally, acute pericarditis requires a period of convalescence and may require work stoppage of 2 to 4 weeks.but work stoppage is not systematic, it all depends on the job and whether there is physical activity or not“, reminds our interlocutor. “In all cases, the return to work must be gradual.

Can you do sports after pericarditis?

Pericarditis contraindicates sport for several weeks since it requires rest. Limiting physical exercise should be considered in non-athletes until symptoms resolve and blood work, echocardiogram, and ECG normalize. The cessation of sporting activity in athletes should be at least 3 months after the onset of pericarditis, recommends a consensus of experts, whose comments were reported by the European Society of Cardiology.

Thanks to Dr Géraud Delesalle, cardiologist.

Sources: Medicines Agency / High Authority of Health / Recommendations of the European Society of Cardiology