Pericarditis

Pericarditis: description

Pericarditis or pericarditis (pericarditis) is the inflammation of the connective tissue surrounding the heart completely. It can be caused by pathogens such as viruses or bacteria, but also by non-infectious reactions of the immune system.

A pericarditis can occur acutely and is often accompanied by strong symptoms. These can be life-threatening, because a common complication of acute pericarditis is an effusion in the pericardium, which narrows the heart muscle and greatly impaired its function (pericardial tamponade). But there are also chronic pericarditis, the insidious and (almost) run without signs of disease.

Structure and function of the heart bag

The pericardium consists of a solid, hardly stretchy connective tissue. It holds the heart in place and protects the delicate heart muscle and its blood vessels. A small amount of fluid from 20 to 50 milliliters lies between the pericardium and the heart muscle and reduces the friction with each heartbeat.

Acute pericarditis

Infections, but also diseases of the immune system (such as rheumatic diseases) can trigger acute pericarditis. In addition, the pericarditis may be the result of a heart attack and occurs when the dead heart muscle is broken down and replaced by scar tissue (Dressler syndrome).

Depending on the course of the acute pericarditis, cardiac specialists divide into different forms: If white-yellowish fibrin deposits form during inflammation (similar to a grave wound when it closes), this is called fibrinous-acute pericarditis.

If bacteria are the cause of pericarditis, there is a possibility that pus forms. This consists of dead immune cells and bacteria. A purulent acute pericarditis is therefore a sign of a fresh bacterial infection.

In some cases, the pericardium is bloody, perhaps as a result of heart surgery, a heart attack or tuberculosis. Even tumors that grow in the pericardium or secondary tumors (metastases) can form a bloody inflammation.

Chronic pericarditis

Chronic pericarditis often occurs when acute pericarditis (despite treatment) does not heal completely and flares up again and again. But even without previous acute course, for example, in a tuberculosis, rheumatological diseases or triggered by drugs or medical radiation (such as a lung tumor), pericarditis can be chronic.

Panzerherz in chronic pericarditis

The chronic inflammatory stimulus forms in the pericardium “calcification” and scarring, which make him immobile and reduce the space for the working heart muscle. In the so-called armored heart, the actually thin protective pouch around the heart can be reduced to a thickness of one centimeter and the heart is severely constrictive (pericarditis).

Pericarditis: symptoms

Typical symptoms of acute pericarditis include pain behind the sternum (retrosternal pain) or throughout the chest. The pain can also spread to the neck, back or left arm and increase when inhaled, coughing, swallowing or by changes in position. Often, people with acute pericarditis also have a fever.

The heartbeat can be accelerated. Cardiac arrhythmias and the subjective feeling of heart stumbling are also common in pericarditis. Depending on the severity of the disease, it can also cause shortness of breath, chest tightness. Since similar symptoms can also occur in an inflammation of the lung or pleura, or especially in acute myocardial infarction, their cause must be clarified immediately.

Chronic pericarditis often lacks symptoms or develops only slowly and therefore goes unnoticed for a long time. In addition to general symptoms of inflammation such as fatigue and decreased performance, the following symptoms may occur with progressive scarring and thickening of the pericardium:

• accelerated heartbeat and flatter pulse
• Shortness of breath during exercise (later also at rest)
• to cough
• jammed (visibly protruding) jugular veins
• edema
• “Paradoxical pulse” (pulsus paradoxus = decrease in blood pressure by more than 10 mm Hg during inhalation

Complication of cardiac tamponade

The heart bag tamponade is a life-threatening complication of pericarditis. It arises when a lot of blood, pus and / or inflammatory fluid accumulates in the pericardium. Since the pericardium can not expand, the effusion narrows the heart muscle and the heart chambers can not stretch properly. This will pump less blood into the lungs (from the right ventricle) or into the systemic circulation (from the left ventricle). The cycle can collapse. A heart bag tamponade is acutely life threatening and must be treated immediately.

Pericarditis: causes and risk factors

Acute pericarditis can be triggered by several factors. Frequently, viruses or bacteria, sometimes (especially in a weakened immune system) and fungi or parasites are the trigger. They pass from the airways or other organs via the blood or lymph vessels to the heart.

But diseases of the immune system or kidneys can cause pericarditis. This includes:

• Renal failure with increased uric acid concentration in the blood
• Autoimmune diseases and rheumatic diseases
• Metabolic disorders (hypothyroidism or hypercholesterolemia)
• Consequences of a heart attack
• Operations at the heart
• tumor diseases

Pericarditis: examinations and diagnosis

If there is a suspicion of pericarditis due to the symptoms, the family doctor will in most cases refer the patient to a cardiologist, a cardiologist. This first asks the medical history:

• Since when do the complaints exist?
• Did the symptoms increase or did new complaints come along?
• Do you feel physically less resilient?
• Do you have a fever – and if so, since when?
• Have you had an infection in the past few weeks – especially the respiratory tract?
• Does the pain in the chest change when breathing or lying down?
• Have you had any complaints or illnesses of the heart before?
• Are you aware of rheumatism or any other disease of the immune system?
• Which medications do you take?

The so-called clinical (physical) examination includes the fever measurement, palpation of the pulse, a blood pressure measurement and the tapping and listening of the chest. With pericarditis, if the effusion is still small, the doctor can often hear a characteristic rubbing with each heartbeat.

A blood sample is used to search for typical markers of inflammation or an infection. This includes:

• an accelerated erythrocyte sedimentation rate
• an increased CRP value
• Increased white blood cells (leukocytosis in bacteria or fungi, lymphocytosis in viruses)
• a detection of bacteria in the blood culture
• increased heart enzyme levels (CK-MB, troponin T)
• increased so-called rheumatoid factors

Various apparatus investigations confirm the suspected diagnosis of pericarditis:

• ECG: abnormal ST segment elevation, flatter or negative T-wave or, in pericardial effusion, overall reduced rash (low voltage)
• Echocardiography (“heart ultrasound”) to prove an effusion
• X-ray examination of the ribcage (“X-ray thorax”, shows only large effusions due to enlarged heart shadow)
• Magnetic resonance tomography (MRI) to visualize the pericardial wall and a possibly existing effusion
• Pericardial puncture (in case of an existing effusion) to assess the condition and to try to detect pathogens

Pericarditis treatment

The first measure of pericarditis is physical rest to relieve the heart. Patients with pericarditis are treated according to the recommendations of the specialist in the hospital, provided that symptoms and test results do not speak for a viral infection. This can also be treated on an outpatient basis. Then the therapy depends on the causes of pericarditis (causal therapy):

at bacterial infections An antibiotic is prescribed that can be given as an infusion to achieve safe levels of effect.

at fungal infections fungicides, so-called antimycotics, are used. These too are often given as short infusions.

virus The causes of pericarditis can not be treated directly, but the symptoms caused by them. It uses anti-inflammatory drugs (NSAIDs such as high-dose acetylsalicylic acid or ibuprofen) and colchicine.

at Autoimmune diseases the excess immune reactions are suppressed with drugs. Suitable active ingredients are, for example, glucocorticoids, cyclophosphamide or methotrexate (“MTX”).

Is a kidney failure the cause of pericarditis, the blood must be purified via a so-called dialysis.

The success of the treatment is controlled by regular ultrasound examinations of the heart. In chronic pericarditis with thickening and scarring of the pericardium (armor heart), the pericardium must be removed by an open-chest surgery (pericardectomy).

Treatment of the heart bag tamponade

Cardiac tamponade (accumulation of fluid in the pericardium that affects cardiac function) is life-threatening and must be treated promptly. To do this, the pericardium is punctured with ultrasound (ultrasonography) from the outside through the thorax with a needle and the effusion fluid withdrawn as much as possible. The patient must then be closely monitored sonographically to detect spillage of effusion fluid or blood early.

Pericarditis: disease course and prognosis

The pericarditis is a serious illness. It may extend to the heart muscle (perimyocarditis) or the entire heart (pancarditis), or by an effusion (serous fluid, pus or blood) to dangerously constrict the heart muscle. If a pericarditis is detected early and its causes and consequences are treated, it can heal without consequences. Untreated is the Pericarditis because of their serious complications (armored heart and heart bag tamponade) a life-threatening illness.