Pericardial Disease

Pericardial disease encompasses a range of conditions that impact the pericardium, the thin, fibroelastic sac that envelops the heart and separates it from the surrounding mediastinal structures. The pericardium plays crucial roles in maintaining the heart's position within the chest, acting as a barrier against infection and inflammation, and lubricating the heart to minimise friction. Understanding the various types and stages of pericardial disease is essential for early detection and appropriate management.

What is Pericardial Disease?

Pericardial disease refers to any disorder or condition that affects the pericardium, the protective sac surrounding the heart. The pericardium consists of two layers: an outer fibrous layer and an inner serous layer. Between these layers is a small amount of fluid that lubricates the heart's surface, allowing it to move smoothly within the chest cavity. When the pericardium becomes inflamed, infected, or filled with excess fluid, it can lead to various forms of pericardial disease, each with its own set of symptoms and potential complications. Recognising the signs and symptoms of pericardial disease is crucial for prompt diagnosis and treatment.

There are several types of pericardial disease, each with its own unique features and causes. These include:

• Pericarditis: An inflammation of the pericardium, which can be acute, subacute, or chronic. It is often caused by viral infections but can also result from bacterial infections, autoimmune disorders, cancer, or chest injury.

• Pericardial effusion: An accumulation of excess fluid within the pericardial space, which can lead to cardiac tamponade, a life-threatening condition where the fluid compresses the heart and impairs its function.

• Constrictive pericarditis: A rare condition where the pericardium becomes thickened and fibrotic, causing the layers to stick together and restrict the heart's movement. It can result from chronic inflammation, infection, or cancer.

• Pericardial fibrosis: Thickening and scarring of the pericardium, which can occur after pericarditis or as a result of systemic diseases such as rheumatoid arthritis.

• Cardiac tamponade: A life-threatening condition where the pericardial effusion compresses the heart, preventing it from pumping enough blood to the rest of the body.

The early signs of pericardial disease include:

• Sudden chest pain, especially if it improves with sitting up and leaning forward

• Shortness of breath, particularly when lying down

• Rapid or irregular heart rhythms

• Fever, if associated with an infection

• Pericardial rub, a rubbing or creaking sound heard with a stethoscope, indicative of pericarditis

The symptoms of pericardial disease can vary depending on the specific condition, but some common signs include:

• Chest pain: This is often sharp, stabbing, or dull and may radiate to the back, neck, or shoulders. The pain typically worsens with deep breathing, coughing, or lying down and improves when sitting up and leaning forward.

• Shortness of breath: Patients may experience difficulty breathing, especially when lying down, due to the heart's inability to fill and pump blood efficiently.

• Fatigue and weakness: A general feeling of tiredness and weakness can occur due to reduced cardiac output.

• Swelling: Fluid buildup (oedema) can cause swelling in the legs, ankles, feet, and even the abdomen.

• Heart palpitations: Irregular or fast heartbeats may be a sign of pericardial effusion or cardiac tamponade.

• Fever: A low-grade fever may be present, particularly if the condition is caused by an infection.

• Cough and hiccups: Pressure on surrounding tissues or nerves can cause coughing, hiccups, or hoarseness.

Pericardial disease can progress through several stages, each with its own set of symptoms and potential complications. These include:

• Acute stage: A sudden onset of inflammation, which can be caused by a viral infection, trauma, or other factors. Acute pericarditis is often accompanied by severe chest pain, fever, and a pericardial friction rub.

• Subacute stage: A gradual onset of inflammation, which can occur weeks or months after the initial triggering event. Subacute pericarditis may present with milder symptoms compared to acute pericarditis.

• Chronic stage: A persistent inflammation that lasts longer than 6 months, often leading to scarring and thickening of the pericardium. Chronic pericarditis can result in constrictive pericarditis, which restricts the heart's ability to fill with blood properly.

• Constrictive stage: Advanced pericardial disease marked by thickening and scarring of the pericardium, leading to restricted heart filling and pumping. This stage may require surgical intervention to restore cardiac function.

Pericardial disease can have various causes, including:

• Idiopathic: In up to 90% of cases, the cause is unknown.

• Infections: Viral, bacterial (e.g., tuberculosis), fungal, or parasitic infections can lead to pericardial disease.

• Inflammatory conditions: Autoimmune diseases such as lupus and rheumatoid arthritis can cause pericardial inflammation.

• Trauma: Direct injury to the chest or heart can result in pericardial disease.

• Surgical complications: Pericardial disease may occur after cardiac surgery or procedures like electrophysiology studies or cardiac catheterisation.

• Metabolic disorders: Conditions like uraemia, hypothyroidism, and some cancers can affect the pericardium.

• Medications: Certain medicines, such as hydralazine, procainamide, and phenytoin, can cause pericardial inflammation as a side effect.

• Radiation therapy: Radiation treatment for cancers in the chest area can lead to pericardial disease.

Pericardial diseases can lead to several serious complications, some of which can be life-threatening if not promptly addressed. These include:

• Cardiac tamponade: This occurs when fluid accumulates within the pericardial space, compressing the heart and preventing it from filling properly. This can lead to decreased cardiac output, low blood pressure, and potentially fatal outcomes if not treated immediately. Symptoms include shortness of breath, chest pain, lightheadedness, and fainting.

• Constrictive pericarditis: This condition is characterised by thickening and scarring of the pericardium, leading to a rigid sac that restricts the heart's ability to expand and fill with blood. Symptoms may include dyspnoea, fatigue, swelling in the abdomen and legs, and poor circulation.

• Heart failure: Untreated pericardial effusion can lead to heart failure due to increased pressure on the heart, impairing its ability to pump blood effectively.

• Recurrent pericarditis: Some patients may experience recurrent episodes of pericarditis, which can be challenging to manage and may require ongoing treatment and monitoring.

Preventing pericardial disease can be challenging because many causes are either idiopathic or result from other underlying conditions. However, some preventive measures can be taken to reduce the risk of developing this condition:

• Infection control: Preventing viral and bacterial infections through vaccination and proper hygiene can reduce the incidence of pericarditis.

• Management of underlying conditions: Effective management of systemic illnesses such as autoimmune diseases, cancer, and renal failure can help prevent pericardial complications.

• Avoiding chest trauma: Minimising the risk of chest trauma through safe practices can prevent traumatic pericarditis.

• Reducing radiation exposure: Limiting exposure to radiation, especially in the context of cancer treatment, can help mitigate the risk of radiation-induced pericarditis.

• Medication management: Avoiding or carefully managing medications known to cause pericardial disease can also help prevent some cases.

Diagnosing pericardial diseases involves a combination of clinical evaluation, laboratory tests, and imaging studies. These include:

• Physical examination: A doctor will assess the patient's symptoms, medical history, and perform a physical exam, listening for specific heart sounds (such as a pericardial rub) that may indicate pericardial inflammation.

• Electrocardiogram (ECG): An ECG can detect changes in the heart's electrical activity that suggest pericardial inflammation or effusion.

• Echocardiogram: This ultrasound of the heart can visualise the pericardium, detect fluid accumulation (pericardial effusion), and assess the heart's function.

• Chest X-ray: A chest X-ray can show an enlarged heart silhouette, suggesting the presence of a pericardial effusion.

• Imaging tests: Computed tomography (CT) and magnetic resonance imaging (MRI) are some of the advanced imaging techniques that provide detailed images of the heart and pericardium, and help identify pericardial thickening, inflammation, or effusion.

• Blood tests: Laboratory tests can help identify signs of inflammation, infection, or underlying conditions that may cause pericardial disease, such as autoimmune disorders or renal failure.

• Pericardiocentesis: In some cases, a sample of pericardial fluid may be obtained through a needle to analyse its composition and identify the underlying cause of the pericardial effusion.

The choice of treatment depends on the underlying cause and severity of the pericardial disease. These include:

• Medications: Acute idiopathic or viral pericarditis is typically treated with nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, or indomethacin. Colchicine is used for recurrent pericarditis or if NSAIDs are ineffective, as it reduces recurrence risk.

• Pericardiocentesis: This procedure involves draining the excess fluid from the pericardial space using a needle, guided by echocardiography or fluoroscopy. It is crucial for treating cardiac tamponade and can be followed by the placement of an indwelling catheter to prevent reaccumulation of fluid.

• Pericardial window: A surgical procedure where a small part of the pericardium is removed to create a "window" for fluid drainage, often used in cases of recurrent pericardial effusion.

• Pericardiectomy: The removal of the pericardium, usually performed in cases of constrictive pericarditis or recurrent inflammatory pericarditis that does not respond to medical treatment.

Living with pericardial disease may require some lifestyle adjustments to manage symptoms and prevent complications. Here are some tips:

• Limit strenuous activities until symptoms have resolved and inflammatory markers have normalised.

• Attend follow-up appointments with your cardiologist to monitor your condition and adjust treatment as needed.

• Take medications as prescribed and report any side effects to your doctor.

• Maintain a healthy diet and manage your weight to reduce strain on your heart.

• Practice stress-reduction techniques, such as deep breathing, meditation, or gentle yoga, to promote relaxation and emotional well-being.

• Seek support from family, friends, or support groups to help cope with the emotional aspects of living with a chronic condition.

If you experience symptoms that may indicate pericardial disease, such as chest pain, shortness of breath, or a rapid heartbeat, it's crucial to seek medical attention promptly. These symptoms can also be signs of other serious heart conditions, so a proper evaluation by a doctor is necessary.

Additionally, if you have been diagnosed with pericardial disease and experience worsening symptoms, new symptoms, or side effects from medications, contact your doctor immediately. Regular follow-up appointments are essential to monitor your condition and make any necessary adjustments to your treatment plan.

• Pericardial disease is a group of conditions that affect the pericardium, the protective sac surrounding the heart.

• Common types of pericardial disease include pericarditis, pericardial effusion, and constrictive pericarditis.

• Symptoms of pericardial disease may include chest pain, shortness of breath, and a rapid heartbeat.

• Treatment for pericardial disease depends on the specific condition and its severity, and may include medications, procedures, or surgery.

• Living with pericardial disease may require limiting strenuous activities, regular monitoring, and lifestyle adjustments.

• If you experience symptoms of pericardial disease or have been diagnosed with the condition, it is essential to work closely with your doctor for proper management and follow-up.