Pericarditis: Symptoms, Causes, Treatment, Diagnosis:
Definition: Pericarditis is an inflammation of the pericardium (the fibrous sac surrounding the heart). Pericarditis is further classified according to the composition of the inflammatory exudate: serous, purulent, fibrinous and hemorrhagic types are distinguished.
Acute pericarditis is more common than chronic pericarditis and can occur as a complication of infections, immunologic conditions, or heart attack.
- Acute pericarditis: May be dry or may cause excessive fluid accumulation in the pericardial space.
- Chronic pericarditis: Fibrous thickening of the visceral and parietal pericardium; thickening inhibits cardiac filling during systole.
Quite often the cause of pericarditis remains unknown, in which case it is called idiopathic pericarditis.
Pericarditis most often affects men aged 20-50 usually following respiratory infections. In children, it is most commonly caused by adenovirus or Coxsackie virus. Causes of pericarditis are as follows:
- Idiopathic: No identifiable etiology found after routine testing.
- Viral infection: especially by Coxsackievirus (most common cause)
- Bacterial infection: especially by the Tuberculosis bacillus
- Immunologic conditions: including Lupus erythematosus (more common among women)
- Myocardial Infarction: (Dressler’s syndrome)
- Trauma: to the heart, e.g. puncture, resulting in infection or inflammation
- Malignancy: (as a paraneoplastic phenomenon)
- A side effect of some medications: e.g. Isoniazid, cyclosporine, hydralazine
- Aortic dissection
- Postpericardiotomy syndrome
- Chest pain, caused by the inflamed pericardium rubbing against the heart.
- Usually relieved by sitting up and leaning forward
- Pleuritis type: a sharp, stabbing pain
- May radiate to the neck, shoulder, back or abdomen
- Often increases with deep breathing and lying flat, and may increase with coughing and swallowing
- Breathing difficulty when lying down
- Need to bend over or hold the chest while breathing
- Dry cough
- Ankle, feet and leg swelling (occasionally)
Exams and Tests
Physical examination: When listening to the down heart with a stethoscope, the health care provider can hear a typical sound called a pericardial rub. The heart sounds may be muffled or distant. There may be other signs of fluid in the pericardium (pericardial effusion). If the disorder is severe, there may be crackles in the lungs, decreased breath sounds, or other signs of fluid in the space around the lungs (pleural effusion).
Diagnostic Test: If the fluid has accumulated in the pericardial sac, it may show on:
- Chest x-ray
- Chest MRI scan
- Heart MRI or heart CT scan
- Radionuclide scanning
These tests show the enlargement of the heart from a fluid collection in the pericardium and signs of inflammation. They may also show scarring and contracture of the pericardium (constrictive pericarditis)
- An ECG is abnormal in 90 % of patients with acute pericarditis. ECG changes generally evolve during the disease process, and they may mimic the ECG changes of a heart attack. To rule out a heart attack, serial cardiac marker levels (CK -MB and troponin l) may be ordered.
Other laboratory tests may include:
- Blood culture
- CBC may show increased WBC count
- C-reactive protein
- Erythrocyte sedimentation rate (ESR)
- Pericardiocentesis, with chemical analysis and pericardial fluid culture
The cause of pericarditis must be identified, if possible
- Use of analgesic: In most types of pericarditis, it is necessary to treat the pain with analgesics (pain killers). The inflammation of the pericardium is treated with anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen. In some cases, corticosteroids may be prescribed.
- Diuretics may be used to remove excess fluid accumulated in the pericardial sac. If the buildup of pericardial fluid makes the heart function poorly or produces cardiac tamponade, it is necessary to drain the fluid from the sac. This procedure, called Pericardiocentesis, may be done using an echocardiography-guided needle or surgically in a minor procedure
- Antibiotic: Bacterial pericarditis must be treated with antibiotics. Fungal pericarditis is treated with antifungal agents.
- If the pericarditis is chronic, recurrent, or causes constrictive pericarditis, cutting or removing part of the pericardium may be recommended.
Pericarditis can range from mild cases that resolve on their own to life-threatening cases complicated by significant fluid buildup around the heart and poor heart function. The outcome is good if the disorder is treated promptly. Most people recover in 2 weeks to 3 months.
- Arrhythmias, such as atrial fibrillation. When pericarditis accompanies myocarditis, other arrhythmias may be present, such as supraventricular tachycardia (SVT) or complete heart block.
- Cardiac tamponade
- Constrictive pericarditis, where inflammation of the pericardial sac results in fibrosis and thickening of the pericardium with adhesions (sticky scars) between the pericardium and the heart. The pericardium creates a rigid “case” around the heart, which can severely limit the ability of the heart to fill with blood. Patients with constrictive pericarditis may develop heart failure, which response poorly to treatment. Constrictive pericarditis must be differentiated from a chronic heart condition called restrictive Cardiomyopathy, which produces symptoms and signs similar to constrictive pericarditis.
- Assess pain using the patient’s self-report when possible. A self-report rating scale assesses the intensity of pain.
- Auscultate the anterior chest to determine the quality of the friction rub.
- Assess respiratory status because the patient may hypoventilate as a result of pain.
- Review the ABGs to evaluate oxygenation and acid-base status.
- Review results of echocardiogram and chest X-ray if available.
- Review serial ECGs for changes.
- Review CBC, leukocyte counts, and culture if possible.
Nursing Interventions for Pericarditis
- Stress the importance of bed rest.
- Assist the patient with bathing if necessary.
- Provide a bedside commode because this method puts less stress on the heart rather than using a bedpan.
- Place the patient in an upright position to relieve dyspnea and chest pain.
- Provide analgesics to relieve pain and oxygen to prevent tissue hypoxia.
- Assess the patient’s cardiovascular status frequently, watching for signs of cardiac tamponade.
- Monitor the patient’s pain level and the effectiveness of analgesics
- Explain all tests and treatments to the patient.
- Before giving antibiotics, obtain a patient history for allergy.
- Tell the patient to resume his daily activities slowly and to schedule rest periods into his daily routine for a while.
- Assess characteristics of pain; administer appropriate analgesics. Upright position, with the client leaning forward, may relieve the pain.
- Decrease anxiety, because the client often associates problems with an MI; assist the client to distinguish the difference.
- Observe for symptoms of cardiac tamponade.
- Paradoxical blood pressure: precipitous decrease in systolic blood pressure on inspiration
- CVP increased; the presence of jugular venous distention.