Pericarditis - home health advice

Overview
Definition

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.
Etiology

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.
Risk Factors

* Chest trauma
* Exposure to viral, bacterial, fungal, or parasitic pathogens

Signs and Symptoms

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

Diagnosis
Physical Examination

See Signs and Symptoms
Laboratory Tests

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)

Pathology/Pathophysiology

* Acute inflammation of pericardium

Imaging

* Chest X ray: small pleural effusion with transient infiltrates
* Chest CT scan or MRI: calcified or thickened pericardium

Other Diagnostic Procedures

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

Treatment Options
Treatment Strategy

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.
Drug Therapies

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.
Complementary and Alternative Therapies

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.
Nutrition

* 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.

Herbs

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.

Homeopathy

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

Acupuncture

Can be very helpful in decreasing inflammation, enhancing immune response, and regulating cardiac function.
Patient Monitoring

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.
Other Considerations
Prevention

If patient is overweight, weight loss is recommended.
Complications/Sequelae

* Pericardial tamponade
* Noncompressive effusion
* Right-sided heart failure

Prognosis

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.
References

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.