Pericarditis: Symptoms, causes and treatment

[6 MIN READ] 

In this article:

• Pericarditis occurs when the pericardium, the sac that surrounds your heart, becomes inflamed.

• Pericarditis can cause chest pain. Here we share some clues that can help you distinguish pericarditis chest pain from heart attack pain.

• A virus, like the common cold, the flu or COVID-19, often causes acute pericarditis. Most people quickly recover from acute pericarditis.

Pericarditis: Symptoms, causes and treatment

Pericarditis is a condition that can cause chest pain. Chest pain can be frightening, especially if you’re unsure of the cause. Is it heartburn? You may wonder. Or is this heart problem pericarditis? Or a heart attack?

We talked to Lori M. Tam, M.D., a cardiologist for Providence in Portland, Oregon, to better understand pericarditis, including what it feels like and the different types, causes and treatments.

What is pericarditis?

Your heart is enclosed in and protected by a sac called the pericardium. Pericarditis occurs when the sac’s two thin layers become swollen, red and irritated, which can result in chest pain. Pericarditis is similar to myocarditis, which is inflammation of the myocardium (the heart muscle).

Anytime you’re experiencing chest pain and think you could be having a heart attack, call 911 immediately. However, there are some key differences between heart attack pain and pericarditis pain. 

With heart attack pain, you may feel pressure, like your heart is being squeezed or tightened. You also may experience pain elsewhere in your body, nausea, lightheadedness and shortness of breath. If you’re having a heart attack, your symptoms will typically worsen.

Pericarditis pain is often sharp and stabbing. It tends to feel worse when you lie down or breathe deeply. The pain comes and goes, usually subsiding when you sit up and lean forward.

Types of pericarditis

There are several different types of pericarditis, and sometimes pericardial inflammation can progress into something more severe. Your treatment plan will vary depending on the type of pericarditis you have.

• Acute pericarditis: This type of pericarditis develops suddenly. It can sometimes be mistaken for a heart attack because you also experience chest pain suddenly.  
• Constrictive pericarditis: Sometimes inflammation can cause your pericardium to grow scar tissue. When this happens, the pericardium’s thin layers thicken, constricting your heart. Untreated acute pericarditis or recurrent bouts of acute pericarditis can lead to constrictive pericarditis. If left untreated, constrictive pericarditis can cause heart failure.
• Chronic pericarditis: If an acute pericarditis attack lasts for more than three months, it’s considered chronic pericarditis. Chronic pericarditis can result in heart failure symptoms, including swelling, shortness of breath and low blood pressure. Thoroughly treating acute pericarditis early on can prevent chronic pericarditis.
• Incessant pericarditis: Acute pericarditis develops into incessant pericarditis when your pericarditis symptoms stubbornly remain, despite therapy, for four to six weeks but then subside before hitting the three-month mark.  
• Recurrent pericarditis: Acute pericarditis develops into recurrent pericarditis when you get a second bout of pericarditis after having no symptoms from your first bout of pericarditis for at least four weeks.

What are the signs and symptoms of pericarditis?

“Patients often describe pericarditis as sharp chest discomfort,” Dr. Tam says. “If they take a deep breath, the pain usually is exacerbated because when the heart stretches a bit more with inhalation, it pushes against the sac and gets irritated. Sometimes certain positions can make the chest pain worse.” 

Lying down puts more pressure on the sac, also causing irritation and pain.

“Sometimes, when patients sit and lean forward, the heart kind of swings forward a little bit,” Dr. Tam says. “There’s less pressure around the sac and the chest pain can get better.”

Patients with acute pericarditis might also notice a fever, shortness of breath and nonspecific viral-type symptoms, but chest discomfort is usually the most common symptom.

“If these symptoms are happening, we want patients to get evaluated,” Dr. Tam says. “Certain blood tests to look for inflammation can help clue us in as to whether someone has pericarditis.”

Your doctor might also use a stethoscope to listen to your heart for a specific sound that occurs during pericarditis called a pericardial rub.

How long does pericarditis last?

The type of pericarditis you have will often determine how long it lasts. But with the right treatment, you can feel better fairly fast.

“It depends on the underlying cause, but usually patients will recover within three months,” Dr. Tam says. “Symptoms can start to get better very quickly after you start treatment.”

What causes pericarditis?

“Typically, the most common cause of pericarditis is a viral infection that causes the inflammation of the pericardium,” Dr. Tam says. “This includes the common cold, the flu and COVID-19.”

Autoimmune diseases can also sometimes cause pericarditis.

“Patients with rheumatoid arthritis or lupus are at higher risk for inflammation in the sac of the heart,” Dr. Tam says. “You can also get pericardial fluid build-up from other kinds of infections like tuberculosis. But it’s less common in modern-day society just because we’ve been able to control the transmission of tuberculosis better. 

Certain medical conditions, such as kidney failure and some types of malignancies, like cancer, can cause pericardial effusion (the buildup of excess fluid in the sac around the heart) with or without pericarditis.

“Certain cancers can metastasize and result in fluid around the heart,” Dr. Tam says. “Usually when we do a pericardiocentesis, which is when we drain the fluid out of someone’s pericardium, we’ll check for cancer cells and make sure there’s no bacterial infection or fungus. This helps us figure out whether there’s something else we need to treat in addition to treating the pericarditis with anti-inflammatories.”

Your risk of pericarditis increases after a heart attack, open heart surgery, a cardiac catheterization procedure or radiation therapy.

Some people are diagnosed with idiopathic pericarditis, meaning the cause is unknown.

Unlike many cardiac diseases, lifestyle factors, such as lack of exercise or smoking, don’t affect your risk of developing pericarditis.

“It’s usually some degree of bad luck,” Dr. Tam says. “When you get a virus, it can affect any of your organ systems. For example, if your virus is affecting your upper respiratory system, you’re going to get congestion, sneezing and a cough. If it attacks your GI tract, you might get diarrhea. If it attacks the sac around the heart, you can get pericarditis.”

There is, however, a simple lifestyle change you can make to reduce your pericarditis risk.

“Minimize infection risks from viruses,” Dr. Tam says. “That includes washing your hands and not being around people who are sick.”

Can COVID-19 cause pericarditis?

“In a very small number of people, and very rarely, pericarditis can be caused by the COVID-19 vaccine,” Dr. Tam says. “It usually occurs in teenage boys. But in most of those cases, patients recover completely with anti-inflammatory treatment.”

For most people, Dr. Tam says COVID-19 vaccines aren’t a concern.

“In patients who’ve actually had pericarditis from the COVID-19 vaccine, we sometimes recommend they avoid future COVID-19 vaccines or at least have a discussion with your physician.”

What kinds of pericarditis treatment options exist?

Typically, the first line of defense against pericarditis is prescription-strength, nonsteroidal anti-inflammatory drugs (NSAIDs, such as Ibuprofen, Motrin and Aleve) or aspirin. Dr. Tam also routinely prescribes colchicine for pericarditis, in addition to NSAIDs, to help control inflammation. Treatment typically lasts up to three months to prevent new flare ups of pericarditis.

“For most patients who have pericarditis, with or without fluid build-up, we want to treat the inflammation,” Dr. Tam says. “If you can control the inflammation, the fluid sometimes will go away with time as the inflammation resolves.” 

In some cases, your doctor may prescribe corticosteroids, such as prednisone, to treat pericarditis.

 “We don’t routinely treat pericarditis with steroids unless they have failed other medications because once you start, it requires a very long course,” Dr. Tam says. “And It’s difficult to wean off because people sometimes get recurrent symptoms with weaning. So it has to be a very slow, long taper.” 

For patients with an autoimmune disease that is triggering pericarditis, treatment may require immune suppressant medications.

Complications: Pericardial effusion and pericardial tamponade

“In certain but not all cases of pericarditis, the inflammation causes excess fluid to build up in the sac around the heart,” Dr. Tam says. “We call this a pericardial effusion. If it’s a mild amount of fluid, sometimes the body will just reabsorb it over time as the inflammation goes away.” 

Pericardial effusion can be diagnosed on imaging tests such as an echocardiogram or CT scan. There may also be findings on an electrocardiogram (ECG or EKG) or chest x-ray which could be suggestive of a pericardial effusion.

Pericardial tamponade, also called cardiac tamponade, occurs when a significant amount of fluid is present, so much so that it pushes on the heart, preventing it from being able to squeeze efficiently and appropriately.

“This can potentially be life-threatening,” Dr. Tam says. “In a very small number of patients, pericardial tamponade can cause cardiac arrest or sudden death because the heart can no longer squeeze blood efficiently and supply blood to other organs.”

How is pericardial effusion treated?

If fluid builds up in the sac but there is no risk of pericardial tamponade, medications can be used to reduce the inflammation. These medications may include aspirin, NSAIDS, colchicine or a corticosteroid. If the fluid build-up is severe, a procedure to drain the fluid or heart surgery may be necessary.

How is pericardial tamponade treated?

“If pericardial tamponade occurs, we usually have to do a pericardiocentesis,” Dr. Tam says. “Under the guidance of an ultrasound, we put a little needle under the skin and into the sac which surrounds the heart. Then we put in a drain and drain the fluid off. If that’s unsuccessful, we have to do a surgical procedure called a pericardial window or pericardiectomy. We don’t usually have to crack open the ribs, which is called a median sternotomy. We just do an incision towards the bottom of the heart to get into the sac for drainage and the surgeon will cut a piece of the pericardium out so the fluid can drain out of the pericardium and stop constricting the heart.”

Recovery

Heart pain can be worrisome. However, pericarditis is easily treated and often has good outcomes. 

“Most patients recover from pericarditis, especially if it’s a virus or if you treat the underlying cause,” Dr. Tam says. “For the vast majority of acute pericarditis cases, people will recover completely from it.”

Contributing caregiver

Lori M. Tam, M.D., is a cardiologist for Providence in Portland, Oregon.

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This information is not intended as a substitute for professional medical care. Always follow your health care professional’s instructions.