Pericarditis natural history
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. ; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. Homa Najafi, M.D.
Pericarditis can lead to the development of pericardial effusion, cardiac tamponade and constrictive pericarditis. Cardiac tamponade, or compression of the heart by fluid in the pericardial sac, reduces the ability of the heart to pump blood. It is a medical emergency that requires urgent pericardiocentesis or a pericardial window. The prognosis depends on the complications of pericarditis, the underlying etiology, and the associated co-morbidities. Pericarditis secondary to malignancy, MI, autoimmune disease and renal failure carries a poor prognosis.
Natural History, Complications, and Prognosis
Pericarditis is inflammation of the pericardium, the double-walled sac that contains the heart and the roots of the great vessels. There can be an accompanying accumulation of fluid that can be either serous (free flowing fluid) or fibrinous (an exudate, which is a thick fluid composed of proteins, fibrin strands, inflammatory cells, cell breakdown products, and sometimes bacteria), which leads to development of pericardial effusion and cardiac tamponade. Vascular congestion of the pericardium is also present. The underlying myocardium may or may not be inflamed as well. If the myocardium is involved in the inflammatory process, it is called myopericarditis, and the CK and troponin levels may be elevated. Subsequent scarring of the pericardium may lead to constrictive pericarditis.
Common complications of pericarditis include:
- Pericardial Effusion
- Many forms of pericarditis can be complicated by significant fluid buildup around the heart, which is known as a pericardial effusion.
- Pericardial Tamponade
- If the fluid accumulates too rapidly or is too large, then cardiac tamponade, a condition in which the heart is compressed by the fluid and cannot pump enough blood forward, may occur. Cardiac tamponade may require urgent intervention including pericardiocentesis or a pericardial window. This complication is more common in patients with specific underlying etiologies such as malignancy, tuberculosis, or purulent pericarditis. It rarely occurs in idiopathic pericarditis.
- Constrictive Pericarditis
- If scarring of the sac around the heart (pericardium) occurs, then this is called constrictive pericarditis which may require surgical stripping of the scar (pericardiectomy).
The prognosis associated with pericarditis depends on the underlying cause and associated condition(s).
- Idiopathic Pericarditis:
- Idiopathic pericarditis is often self-limited and most patients recover in 2 weeks to 3 months. Idiopathic or viral pericarditis is associated with a favorable long-term prognosis with few developing recurrences. Approximately 15-30% of patients with idiopathic acute pericarditis who are not treated with colchicine will develop recurrent pericarditis.
- Post MI Pericarditis or Dressler's Syndrome:
- Post MI pericarditis is usually associated with larger infarcts, and therefore these patients have a poorer long term prognosis.
- Tuberculous Pericarditis:
- The mortality rate associated with tuberculous pericarditis in the preantibiotic era was 80-90%. The mortality is 17-34% if the tuberculous pericarditis is associated with HIV.
- Traumatic Pericardial Injury:
- In penetrating injuries, pericardial effusion and tamponade may develop rapidly. Early detection and early treatment of cardiac tamponade is associated with a good prognosis. Minor perforations, isolated right ventricular wounds, and a systolic blood pressure more than 50 mm Hg are all associated with better outcomes.
- Malignant Pericarditis:
- Pericarditis associated with malignancy is associated with poorer outcomes and a more complicated course.
- Autoimmune Disease:
- Pericarditis associated with scleroderma and rheumatic fever is associated with worse outcomes.
- Renal Failure:
- Pericarditis associated with renal failure is associated with significant morbidity and may result in hemorrhagic pericarditis.
- ↑ Mayosi BM, Burgess LJ, Doubell AF (2005). "Tuberculous pericarditis". Circulation. 112 (23): 3608–16. doi:10.1161/CIRCULATIONAHA.105.543066. PMID 16330703.
- ↑ Ilan Y, Oren R, Ben-Chetrit E (1991). "Acute pericarditis: etiology, treatment and prognosis. A study of 115 patients". Jpn Heart J. 32 (3): 315–21. PMID 1920818.
- ↑ Shabetai R (1990). "Acute pericarditis". Cardiol Clin. 8 (4): 639–44. PMID 2249218.
- ↑ Harvey AM, Whitehill MR. Tuberculous pericarditis. Medicine. 1937; 16: 45–94<ref name="pmid10908256">Hakim JG, Ternouth I, Mushangi E, Siziya S, Robertson V, Malin A (2000). "Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients". Heart. 84 (2): 183–8. PMC 1760932. PMID 10908256.
- ↑ Nicholls, AJ. Heart and Circulation. In: Handbook of Dialysis, Daugirdas, JT, Ing, TS (Eds), Little, Brown and Co., New York 1994. p.149.