my name is sanjay gupta i'm a consultant
cardiologist in york
and today's video is on the subject of
pericarditis someone actually wrote to
me and said look you
know i've been diagnosed with
pericarditis i'm very worried about it
could you do a video on it and
as you know i'm currently quarantining
and therefore i have
a bit of time so i thought let's go for
it so here is a video on pericarditis
okay so pericarditis refers to
inflammation of the pericardium
what is the pericardium the pericardium
is a sac
within which the heart sits so the heart
is enclosed by
it sits within a sac called the
pericardium and this sac has two layers
one is called the visceral layer the
other is called the parietal layer
and these layers are separated by a
potential space which contains a little
bit of fluid 10 to 50 ml of fluid
when you have acute inflammation of this
sac that is called acute pericarditis
if the inflammation spreads from this
from the
sac to the surface of the heart itself
it is termed
myopericarditis about five percent of
all patients who present to
accident in emergency with chest pain
which is not deemed to be a heart attack
or angina
are ultimately diagnosed with
pericarditis so it's fairly common
the question is why does this
inflammation happen and there are a
multitude of causes but
by far and away the most common causes
certainly in the western world
is a presumed viral infection the cause
the commonest cause depends on geography
which part of the world you're in so in
developed countries the commonest cause
of acute pericardium
cardiac is a presumed viral infection
common viruses that can cause this are
parvovirus b19
epstein-barr virus which causes
glandular fever as well
cytomegalovirus herpes simplex virus
etc in developing countries the
commonest causes of pericarditis are tb
and hiv there are lots of other causes
of pericarditis as well including
bacterial infections
kidney failure rheumatological
conditions or autoimmune conditions such
as
sle lupus rheumatoid arthritis
sarcoid uh pericarditis can even be
caused by cancer
mesothelioma spread from other tumors
like
lung cancer or breast cancer also if
you've had recent cardiac surgeries if
you've had a bypass operation where
people have manipulated the sac
then the sac can get inflamed and that
can present with
acute pericarditis and even a recent
heart attack so
some people after a heart attack a few
days after a heart attack will develop
pericarditis
now how does it present well it may
present out of the blue so you're
completely fine and then one day you
wake up and you've got the symptoms of
pericarditis which i'll talk about
but often it may also present after a
flu-like
respiratory or gastric illness
now pericarditis is often characterized
by very severe chest pain
but it's usually reasonably easy to
distinguish from
anginal pain because in pericarditis the
pain is very sharp and it actually
catches
the breath when a person strives to
breathe in it's made
worse when the patient coughs it is
characteristically one of the
characteristics of this condition is
that
the pain gets better when someone sits
up and leans forward so you would be
in terrible pain when you're lying down
but if you sat forward
lent forward you would feel better and
this is because this position reduces
the pressure on the pericardium
pain is a feature in over 95 percent of
patients
it is very prevalent in patients with an
infection like a viral infection but if
you have
pericarditis because you have kidney
failure or possibly some rheumatological
conditions
then the pain may not be as prevalent or
as severe
one of the interesting things about this
pain is it may radiate
to the trapezius ridge and that's
very suggestive again and
one of the things that is very helpful
when you're making the diagnosis
pericarditis is for the doctor to listen
to the heart
and the reason they listen to the heart
is they're listening for something
called a pericardial friction rub
remember you have the two layers of the
pericardium and if both layers are
inflamed
when the heart moves within the
pericardium these two layers
rub against each other because of the
inflammation and that can produce
this scratchy squeaky noise that can be
heard by a stethoscope
and an experienced doctor the absence of
a rub does not
exclude the possibility of pericarditis
but the presence makes it
very likely that this is what you're
dealing with
the best way to hear it you know
sometimes doctors make the mistake where
they just listen to it actually what you
have to do is get the patient to lean
forwards
and even hold their breath or even get
on your hands and knees and the doctor
can
listen to you when you're in that
position of course that can be difficult
if you're in a lot of pain
but that's one way to hear that noise
pericarditis can be associated with ecg
changes
specifically something called st
elevation st elevation is very
important because st elevation is also
something that you see on the ecg in a
person who's having a heart attack
and therefore you know pericarditis can
sometimes be mistaken for a heart attack
and vice versa it's important to know
how to distinguish between the st
elevation you see in pericarditis
compared to the st elevation you see in
a heart attack sometimes it can be
incredibly difficult
but the important thing is you have to
make that distinction because if you
have pericarditis and you get the
treatment for a heart attack then that
could actually do you harm
and of course if you think it's
pericarditis and someone is having a
heart attack then you may be depriving
them of that treatment which could
improve their prognosis from the heart
attack and so it's important to make
that distinction
and the way you make the distinction
between pericarditis and a heart attack
is that the st elevation you see in
pericarditis
tends to be concave it tends to be
saddle shaped
whereas the st elevation st elevation is
an ecg pattern whereas the
sd elevation you see in a heart attack
tends to be a little bit more
convex in addition in pericarditis
because you're dealing with inflammation
of all of this pericardium which is
around the heart
the st elevation seems to be seen in all
the leads okay or seems to be very
widespread in the majority of the leads
with a heart attack however the problem
is a blockage in a vessel which is
supplying
a certain area of the heart and
therefore you would only expect to see
the
elevation in those chains in those leads
that are
that are supplying that particular
territory that are looking at that
territory which is being supplied by
this blood vessel which is blocked
so having said that you know sometimes
it can be incredibly difficult and you
have to put everything into context you
have to see the patient is the patient
describing
sharp pain which is better when they sit
forward or is that are they describing a
dull heavy sensation like an elephant
sitting on their chest
um if someone comes to me and they're
describing a dull heavy sensation
and they look grey and it looks like
someone said they feel like someone's
sitting on their chest
then i would think that's a heart attack
no matter what the ecg shows
whereas if it was if it's a young guy
otherwise completely fit and well
sharp pain otherwise okay then i would
think
more pericarditis but usually you need
an experienced doctor to make that
diagnosis
we see typical ecg changes in about 60
of patients with pericarditis and
actually when we see ecg changes it
tells us that there's some irritation
of the heart itself rather than just the
sac
as i say this is not an absolute finding
and sometimes
these differences between a heart attack
and pericarditis can
even mislead experienced professionals
now what else can be helpful
blood tests up to 80 of patients with
pericarditis will have
elevated markers of inflammation such as
an elevated white cell count
elevated crp levels 30 percent of
patients with pericarditis
may even have an elevation of their
troponin levels troponin is a marker of
heart muscle damage and when the
troponin is elevated a lot of people
immediately think oh this patient's
having a heart attack but it's not true
sometimes the troponin can be elevated
because of inflammation of the
pericardium which is also spreading to
the myocardium
in that sense you know pericarditis has
a much better prognosis than a heart
attack so it's important to make that
distinction
um but when you see the troponin to be
elevated it does signify that there's
some inflammation of the heart muscle
itself
and in that sense the diagnosis would
then be termed
myopericarditis who needs to stay in
hospital
with pericarditis well if you have fever
above 38 degrees
if the symptoms have presented over a
number of weeks rather than suddenly
if you've not responded to simple
treatment like anti-inflammatory
painkillers
if you're immunocompromised or if
there's evidence of
fluid in this cavity that potential
space i was talking about i.e
pericardial effusion
then it is perhaps a good idea to stay
in hospital as
these features point to a more
complicated
course of disease i'm going to talk
about the pericardial effusion in a
second
and so those are the people who should
probably stay in hospital
if the pain is mild if you're otherwise
okay there are no other issues then
it's quite reasonable to be at home what
are the complications associated
with pericarditis now generally the
prognosis of pericarditis depends on the
cause of the pericarditis
if it is a viral cause which by far is
the commonest cause in
the develo developed world then the
prognosis is generally excellent and
people
tend to make a full recovery with
settling of their inflammatory markers
with resolution of their pain
with recovery of their um you know
physical functioning
within four to six weeks the main
problem for most patients
is really the pain that they experience
and often the pain can be very severe
and they often need to be in hospital or
have some symptomatic relief with strong
painkillers
with strong painkillers the pain usually
responds well
if the pericarditis is due to a
bacterial infection or due to cancer
then the pericarditis can be dangerous
and is associated with a much higher
mortality almost 20 to 30 percent
there are a few things to be aware of
which may complicate pericarditis
firstly if there is a lot of
inflammation
then you can get a buildup of fluid in
this space between the two layers of the
pericardium and this can therefore
take up a lot of space and therefore
because the heart
sits in this sac and if the sac
has got fluid which is building up
between its two layers
then in some ways it's going to restrict
the heart from filling up
filling up with blood and when that
happens
because the heart is not able to fill
with much blood it's not able to pump
much blood out
and that can become a life-threatening
emergency because
of a lack of blood going around the body
so when you have
fluid in in the peric in this space
between the two layers of the
pericardium it's called a pericardial
effusion
and you may have fluid which doesn't do
anything which is not actually having an
effect on the hemodynamics of the heart
or you may have a build up of a lot of
fluid
you know a lot of fluid and that can
actually start compressing the heart
and stopping it from relaxing or filling
up with blood and therefore
one of the most important investigations
in anyone who comes in with pericarditis
is to do a scan of the heart
and just make sure they're not they
don't have an effusion
if the effusion is just sitting there
and it's not bothering the patient then
you don't need to do anything about it
you just treat the pericarditis and the
fluid will go away
on the other hand if the fluid is
beginning to compress the heart
and there is evidence that there's a
lack of blood
going around the body as evidenced by
blood pressure falling heart rate being
very high the patient getting very
breathless
then in that setting that becomes a
medical emergency and you actually have
to go
in and take that fluid up and you can do
that just by sticking a needle
into the pericardium under local
anaesthetic and then just tapping that
fluid and draining the fluid out
but if you leave it then there's a very
high mortality
particularly if it's already beginning
to cause compression if
as i say if it is not causing
compression if the patient is completely
well
then just treat the pericarditis and the
fluid will
settle over a period of time that's one
complication
and one of the things that may give you
a clue about fluid buildup is the chest
x-ray so if the heart looks
big on the chest x-ray then that points
to maybe fluid around the pericardium
and that is why
i think anyone who comes in with
pericarditis should
have a heart scan just to know whether
there's any
fluid building up the second thing to
say is that if there is bad inflammation
of the pericardium then sometimes these
two layers
these two layers can stick to each other
and this can then
stop the pericardium from being
compliant because these two
layers have stuck to each other and
therefore
when the heart is moving there's a
restriction because of these
layers being stuck together with you
know all this inflammation and scar etc
and when that happens the heart is no
longer now sitting in a nice
plant bag but it's more like it's
sitting in a hard stiff case and again
this can have the effect
of stopping the heart from filling with
blood because when the heart tries to
fill with blood
it's restricted by this pressure from
this hard
case that it's sitting in and this
therefore means that if the heart fills
with less blood
it has less blood to pump out this
condition
is termed constrictive pericarditis
constriction
and it complicates about one percent of
pericarditis this is a problem that
becomes troublesome several months or
years after the event of pericarditis
and many patients may then present with
breathlessness
leg swelling signs of heart failure but
when you then scan the heart you say oh
look it's
pumping okay so you may be misled into
thinking that it's not heart failure
because the heart is pumping well
the problem is not that the heart cannot
pump the problem is that the heart
cannot relax and fill with blood
so it's pumping but it's not really
pumping much blood out
and therefore if someone has had
pericarditis and then
a year down the line or two years down
the line they start finding that they're
getting more breathless on exercise
their legs are beginning to swell up
then it's very important that history of
pericarditis may be relevant
because it may be constriction
um as i say this is an infrequent uh
problem it tends to be more in people
who have recurrent pericarditis
one percent of um the population
one percent of pericardite carditis can
be complicated
by constriction the important thing
about this is that of course if you have
that condition
constriction then this is a potentially
curable condition right because what you
can do is you can surgically remove this
hard casing which the heart is sitting
within and then the heart can relax and
start filling up with blood
the important thing is that someone has
to be able to think about it
when it when someone presents with that
and say okay you have to bear it in mind
that it could be constriction because it
can be easily missed
and then the patient may be put on lots
of medications for
heart failure and they're not getting
better because the problem is a
mechanical one
and eventually someone will say okay oh
my god this was a constriction
and you send them for an operation and
you know the problem goes away
i had one patient when i just started in
york who for
10 years was being treated with heart
failure treatments and he was just
in and out of hospital in and out of
hospital and i recall seeing him and
then he
just casually mentioned i would have
missed it but he casually mentioned he'd
had pericarditis and i thought oh
could he have constriction and indeed he
did turn out to have constriction
we sent him for an operation and he's
now leading a completely normal life not
requiring any medications feeling really
well
so it's a very satisfying condition to
diagnose and treat uh but doctors have
to be alert to that so if you've had
pericarditis before
and then later on in life you start
getting breathless it's important to
remember that and mention that to the
doctor
another problem is that sometimes if you
have myocardial involvement
i.e the inflammation is spreading from
the pericardium into the heart
ie myopericarditis then sometimes the
heart can weaken because of this
inflammation
and again the echo will show that up and
if this is the case then the patient may
require supportive treatment with for
medicaid with medications for heart
failure
diuretics ace inhibitors beta blockers
the good news is once the pericarditis
settles and patients are put on these
medications the heart
generally strengthens back up in more
than 90 percent of cases
within a few months to a year perhaps
the biggest problem
with pericarditis is about 30 percent of
pericarditis can become recurrent
especially if we don't use a medicine
called
colchicine in the treatment initially
i'll talk you through the treatment of
pericarditis first and then
i'll talk you through a little bit about
the treatment of recurrent pericarditis
so once pericarditis is diagnosed it's
really important that
the pain is controlled because patients
do experience a lot of pain which is
very uncomfortable
and in that sense what we try and do is
we use anti-inflammatory agents which
also act as painkillers such as
non-steroidal anti-inflammatories such
as aspirin
and broofin ibuprofen they're generally
used but they're used at much higher
doses
so a typical dose of bruifin will be 600
to 800 milligrams every 8 hours or
aspirin
750 to 1 gram three times a day
a lot of anti-inflammatory and the
problem of course with these
non-steroidals is
that they do increase the risk of ulcers
by almost four-fold
they can increase blood pressure they
can affect the kidneys so
therefore they may not be for everyone
but it is always good to check
with the doctor to see if these would be
indicated in your case
another medication that i've already
mentioned is colchicine colchicine is an
anti-inflammatory
i've actually done a video recently on
the benefits of culture scene
and colchicine is usually recommended in
addition to the non-steroidals because
colchicine has been shown to
significantly reduce symptoms
and symptoms at 72 hours
and is also associated with a reduced
recurrence of pericarditis so
recurrent pericarditis is less common in
those people who are given colchicine
during their index
episode of pericarditis once the
inflammatory markers start settling down
the inflammation starts settling down
the colchicine can be tapered down
you can also use steroids for patients
who do not respond to non-steroidals or
colchicine one can use
low-dose steroids i want to emphasize
ludos because hydrosteroids
peroxide paradoxically have been linked
with an increase in
risk of recurrence but ludo steroids can
be helpful
in reducing the inflammation and
altering the course of the
pericarditis as i say some people
develop 30 develop recurrent
pericarditis which is a real problem
which means that after four to six weeks
after a few months the pericarditis
comes back and in those people you can
use
stronger immunosuppressants such as
methotrexate
myco phenylate azathioprine etc there is
a new set of
medications called il1 blockers one of
them is called anakinra
which may also reduce recurrent episodes
but there's more studies being done with
this
finally if none of these measures work
and
a patient is really troubled with
recurrent pericarditis
then it may be possible to do a
pericardectomy which means
you remove the sac surgically and
therefore you won't get the inflammation
of the sac
one other thing to know about is that if
you're a competitive athlete and you've
had pericarditis then it is generally
recommended that you abstain from
competition for about three months
but people who are non-competitive
athletes just normal people you know you
can start doing a bit of exercise after
all the inflammatory markers have come
down
so here's a little bit about
pericarditis i hope you enjoyed this
video it's a little bit more of a niche
subject
but who knows someone may be having
pericarditis and they may have some
questions and i hope this
video has gone some way into trying to
answer these questions in general
pericarditis is a self-limiting
illness it is not dangerous and the
prognosis
is generally very good it can be very
very painful though
and that's why i think it's important to
know about the medications that we can
use
to try and make symptoms better so i
hope you found this useful
and once again thank you so much for all
that you do for me all the best
you