Pericarditis / Heart Bag Inflammation and Rheumatic Disease 4.33/5 (3)

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Chest X-ray. A: chest X-ray shows patchy consolidation with multiple nodular densities in both the lower lung fields and cardiomegaly. B: chest X-ray following treatment with steroids shows improved consolidation and cardiomegaly.
Pericarditis by SLE (Lupus). Enlarged heart and seals in the lungs (A). Normally after treatment (B). Park KT, 2011. CC BY NC 3.0


Heart bag (pericardium) is sac-shaped and surrounds the heart. It consists of two layers of connective tissue. Pericarditis means inflammation between these layers (visceral / inner layers and parietal / outer layers). Usually this space contains 15-50 ml of liquid (reference: Hoit PD, 2017). Pericarditis is pericarditis. In pericarditis, this volume can increase so that pressure occurs (tamponade) and the heart's pumping function (contractility) is reduced. Pericarditis is divided into acute (4-6 weeks), subacute, chronic (> 3 months) and recurrent (after 4-6 weeks symptom relief) forms. Usually a liquid is then a so-called exudate containing fibrin. Pericarditis is usually examined and treated by a cardiologist.

Disease Causes


Bacteria: Tuberculosis, borelia. Treatment: The underlying infection is treated.

Virus; Adeno-virus, Coxackie-B, EBV (Epstein-Barr), CMV (Cytomegaly), Parvo virus B19. Treatment: The underlying infection is treated.

Autoimmune rheumatic disease

Autoinflammatory / Periodic Fever Syndromes

After heart disease

  • After a heart attack (Dressler syndrome); After heart surgery and other heart procedures

Symptoms of pericarditis

Acute pericarditis is one of the most common heart-bag diseases and a common cause of chest pain. The pain is felt behind the sternum and is sharp with varying intensity. It can radiate to the neck, jaw or arm, such as angina pectoris, but does not respond to nitroglycerin. The condition is most common in men aged 20-50 (Snyder MJ, 2014). Recurrent pericarditis accounts for 30% of cases.

Typical symptoms of pericarditis include Pain in the chest that is relieved by sitting up and worsens when lying flat (“… have to sit up all night…”) The pain can radiate to the shoulders and back. Fever. Feeling sick. High CRP in blood tests is common.

Examinations in pericarditis

Medical history should cover typical symptoms (see above), previous cases and predisposing conditions such as ongoing or recent infection and rheumatic diseases

Clinical medical examination includes auscultation of heart with stethoscope. One can hear pericardial rubbing sound at 35-80%. This is caused by friction between the tissue layers. However, the sound is variable and often only audible in certain locations and positions. With increasing fluid in the pericardium, the rubbing sound will disappear. Clinically, signs of infection, rheumatoid arthritis, concomitant "water on the lungs" (pleural fluid) and other signs of "systemic disease" are also considered.

Blood tests may include: SR, CRP, liver enzymes, leukocytes with differential count, platelets, peripheral blood smears, ferritin, CK, troponin, D-dimer, electrophoresis, AST, «rheumatoid samples» such as ANA, ANCA, anti-CCP. Antibody to the virus chlamydia pneumonia and a urine swab are also relevant.

Imaging with ultrasound of the heart (echocardiography), X-ray or CT of the lungs and / or MRI of the heart may be appropriate

ECG: shows signs of disease in> 50% (with ST elevation in acute stage, T-inversions later in the course).

Sspecial investigations: Drainage of pericardial fluid (pericardial synthesis) with analysis of pericardial fluid: leukocytes, cytology.

Course of disease

Complications: Cardiac muscle disease (15%), cardiac tamponade (1-2%), recurrent (15-30%), recurrent recurrence (6%), constructive pericarditis (chronic: 1-2%). Reference: Creams, 2016

Similar conditions / differential diagnoses for pericarditis

Symptoms and findingsAcute pericarditisAngina or heart attackPulmonary embolism (blood clot in the lung)
Chest pain
LocationBehind the sternum (retrosternal)Behind the sternum front, back or side of the chest
DurationHours to daysMinutes (angina) to hours (heart attack)Hours to days
SymptomSharp, prickly, sometimes oppressivePressing, heavy, squeezingSharp, prickly
Change when changing positionDeterioration lying down, improvement in sitting or leaning
Changed by breathingGlassinAbsent when holding your breath
RadianceJaw, neck, shoulder, one or both arms, between shoulder bladesJaw, neck, shoulder, one or both armsShoulder
Response to nitroglycerininBetterin
Clinical examination
Friction sound when the doctor examines / auscultatesOccurs in 85% of patientsAbsent (unless pericarditis is also present)Rarely; 3%
Literature: Snyder MJ, 2014

Treatment of pericarditis

In pericarditis, measures against possible underlying disease is important. NSAIDs against pain are most common symptom-relieving measures. In case of unknown cause or viral pericarditis, NSAIDs (eg ibuprofen 600-800 mg x 3) are often combined with Kolkisin tablets (eg 0,5 mg x 2 at weight> 70 kg, 0,5 mg x 1 at lower weight). In viral pericarditis, the symptoms will usually return after two weeks of treatment. Corticosteroids such as prednisolone are not the first choice, but may be necessary in some cases (Snyder MJ, 2014). Steroid-dependent recurrent pericarditis may benefit from supplemental immunosuppressive drugs (DMARDs) such as Imurel / azathioprine, IVIG (immunoglobulins) or anakinra (IL-1 receptor antagonist, biological) to reduce the need for corticosteroids (Finetti M, 2014). The medication is reduced and discontinued when the condition has calmed down.


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