Before we begin with the symptoms of pericarditis, one should know what pericarditis is clinically.
Pericarditis refers to the inflammation of the pericardium. Pericardium refers to a double-layered sac which comprises of a visceral pericardium separated by a small quantity of fluid from the fibrous parietal pericardium. The pericardium also has two roles.
Prevents Sudden Dilation- By exerting restraining force it stops sudden dilation of cardiac chambers.
Provides Protection: It restricts anatomical position of heart & stops the spread of infection from lungs to pericardium. Thus, it provides protection against exogenous infection.
What are the Symptoms of Pericarditis?
Pericarditis has few major diagnostic features. Pain in the chest is most commonly observed in acute infectious pericarditis. Pain in the chest region can even occur in many other forms which are associated with hypersensitivity/autoimmunity. Pain is often severe, retrosternal & left precordial & referred to the neck, arms/left shoulder. Pain sometimes radiates to either arm/both the arms & resembles myocardial infarction, thus it should be differentiated from myocardial infarction.
Pain may be relieved by sitting up & bending forward & is intensified by lying in supine position, thus position plays an important role in diagnosis.
How to Differentiate it From Myocardial Infarction?
Differentiation becomes difficult when pericarditis involves epicardium in the inflammatory process resulting in myocyte necrosis thus markers of myocardial infarction such as troponin & creatinine kinase also rises. However, these elevations are quite modest associated with ST elevation in pericarditis. This helps in differentiating the two conditions.
Pericardial Friction Rub- This friction rub is audible in almost 85% of the patients having 3 components per cardiac cycle. It is high pitched & described as a scratching, rasping/grating sound. Most heard at end expiration & leaning forward condition.
ECG Findings- It involves four stages-
- Widespread elevation of ST segment often with upward concavity. Depression of the PR segment below TP reflecting atrial involvement.
- T-wave becomes inverted.
- After few weeks/months, ECG finding comes to normal.
- Q-wave may develop with loss of R wave amplitude & T-wave’s inversion is seen within hours.
Pericardial Effusion- It is important when it develops within a short period of time because it may lead to cardiac tamponade. Heart sounds are fainter in effusion. At times due to excessive fluids, the base of the left lung may be compressed by pericardial fluids producing Ewart’s sign, a patch of dullness & increase fremitus beneath the angle of the left scapula.
The chest roentgenogram may show enlargement of a cardiac silhouette with a water bottle configuration.
How will you Diagnose Pericarditis?
Echocardiography is the most widely used imaging technique. It is sensitive, specific, & non-invasive. The presence of fluid is recorded by two-dimensional transthoracic echocardiography.
In the condition where there is excessive fluid in pericardium heart may appear swinging freely in the pericardial sac.
CT scan & MRI are even performed if one wants to know specific location.
Treatment of Pericarditis
- Bed rest.
- Anti-inflammatory drugs – aspirin with gastric protection omeprazole.
- NSAIDs are even useful- indomethacin. If patients are unresponsive to this treatment then colchicine may be used (should not be used in a patient with hepatic/renal problems)
- Glucocorticoid’s (Prednisone 1 mg/kg/day) usually suppress the clinical manifestation of acute inflammation, but increase the risk of recurrent attacks.
- In a person who does not respond to all the aforementioned drugs the last choice of treatment is pericardial stripping.
Pericarditis is of several types which include-
- Acute pericarditis.
- Viral/idiopathic acute pericarditis.
- Chronic pericardial effusion.
- Chronic constrictive pericarditis.
Points to Remember about Pericarditis
Pericarditis is the inflammation of the pericardium, double sac membrane surrounding the heart & provides it with structural support.
Symptoms include chest pain which is severe & sudden in onset associated with referred pain in shoulder & neck.
ECG finding will differentiate it from myocardial infarction.
Diagnosis is made by echocardiography & this is the investigation of choice.
Treatment consists of the use of anti-inflammatory drugs, colchicine, NSAIDs, & corticosteroid. The last resort is pericardial stripping.