How to Sleep with Pericarditis?

Overview

• Pericarditis is the inflammation of the pericardium (sac surrounding the heart, preventing friction). There are different types depending on severity and duration.
• Pericarditis is typically idiopathic, caused by a variety of factors such as viral infection, heart surgery and certain medications.
• The most notable symptom is sharp chest pain - always seek immediate medical help when experiencing chest pain.
• Lying down makes symptoms worse.
• The best sleeping position for pericarditis has not been specifically researched. However, the best position is sleeping on the right side for most heart conditions.
• Rest and avoid strenuous exercise until symptoms have gone or test results are normal.
• Treatment options include NSAIDs such as aspirin and ibuprofen in conjunction with colchicine, for acute cases. More severe cases may require surgical intervention such as pericardiocentesis.

What is pericarditis?

Pericarditis is the inflammation of the pericardium. The pericardium consists of two thin layers of connective tissue with a small cavity. The role of this structure is to protect the heart and reduce the friction between the heart and nearby structures, whilst it expands and contracts.¹

Pericarditis is caused by excess fluid or blood leaking into the sac. It is more common in males, particularly between the ages of 16 and 65. It is estimated that 0.028% of the population is affected by this condition.² 

What causes pericarditis?

Pericarditis can occur for a variety of reasons, hence diagnosis requires investigation. Approximately 90% of cases are idiopathic, meaning that they arise spontaneously. A common cause for the other 10% of cases is a viral infection, typically in the respiratory or digestive system.

Other causes may include:

• Heart attack or heart surgery
• Kidney failure 
• HIV/AIDs 
• Cancer
• TB
• Certain medications (phenytoin, warfarin, heparin, procainamide)

Symptoms of pericarditis

Pericarditis causes sharp chest pain that can be described as a stabbing feeling. Occasionally some experience a dull, achy chest pain instead. The chest pain is felt mostly on the left side, behind the breastbone - where the heart is located.

This pain can spread to the left shoulder and neck. It can become aggravated whilst coughing, breathing deeply or lying down. Conversely, it may feel better whilst sitting up or leaning forward.

REMEMBER: It is important to seek medical attention as soon as possible when you experience chest pain.

Other symptoms of pericarditis may include:

• Coughing
• Weakness and fatigue
• Leg swelling
• Mild fever
• Heart palpitations
• Abdominal swelling
• Shortness of breath whilst lying down³

However, specific symptoms are dependent on the type of pericarditis experienced.

Types of pericarditis

Acute pericarditis

This type has a sudden onset, which can make it hard to distinguish from pain associated with a myocardial infarction. The episode does not last more than three weeks, but further episodes can occur.

Recurrent pericarditis

Following an episode of acute pericarditis, this type is the subsequent episode. There tends to be a gap of four to six weeks, during which the individual is asymptomatic.

Incessant pericarditis

With continuous symptoms, incessant pericarditis typically lasts four to six weeks but is less than three months.

Chronic constrictive pericarditis

With a slower onset of development, it lasts over three months. Constrictive pericarditis involves the pericardial tissue becoming stiffer or thicker. This is a result of the tissue becoming scarred. Thickening can also lead to more complex issues including pericardial effusion and cardiac tamponade (see pericardial effusion section).⁴

Diagnosis of pericarditis

Diagnosing pericarditis requires looking at medical history, a physical examination and running diagnostic tests.

Alongside general medical history questions, the physician will consider recent illnesses with flu-like or respiratory symptoms. As well as this, they are likely to ask about angina, chest injuries or myocardial infarction.

The physical exam involves the physician using a stethoscope to listen to the chest sounds present. The excess fluid in the pericardium causes it to rub against the outer heart tissue, creating a characteristic sound known as ‘pericardial rub.’

Vitals, such as blood pressure, heart and respiratory rate will also be checked. 

With respect to diagnostic tests there are a few options, depending on the outcomes of the medical history and the physical examination.

These include:

• Electrocardiogram (ECG): an ECG trace shows the electrical activity of the heart. Ten excess fluid in the pericardium (pericardial effusion)  can cause it to press on the heart, affecting its activity (cardiac tamponade).
• Chest X-ray: this will show the excess fluid in the pericardium as the region will show up more dense than usual. 
• Echocardiogram: This type of ultrasound scan looks at the functioning of the heart as well as the presence of fluid. It is great at showing the thickness of the pericardium in constrictive pericarditis.
• Cardiac CT: This scan is used to look for calcium in the pericardium, inflammation or thickening of the pericardium or even see compression of the heart.
• Cardiac MRI: Looks for the presence of fluid in the pericardium or the presence of inflammation or thickening of the pericardial tissue.⁵ 
• Blood test: will look at the cardiac biomarkers troponin, which tends to be elevated. It will also look at white blood cell count and C-reactive protein levels, both of which are elevated when there is inflammation.⁶

Managing Pericarditis 

What are the best sleeping positions?

Lying down with pericarditis can make symptoms feel worse, so many individuals struggle with sleeping comfortably.

Although there is a lack of research into the best sleeping positions for pericarditis, it is suggested that sleeping on the right side may be the superior option. 

This is because sleeping on the left side may put pressure on the left side of the heart. Despite a lack of evidence for this, a 1997 study found that, when an ECG is conducted whilst lying on the left side, there are changes in the ST region as well as the QRS complex. This shows that sleeping on the left side has some effects on the heart.⁷

Sleeping on the back is also not recommended as it affects sleep apnea and can increase snoring.⁸

Resting and avoiding exercise

Whilst suffering from pericarditis, it is important to rest and avoid strenuous exercise. Rest is extremely encouraged with pericarditis to avoid further complications, such as: 

• Increased risk of myocarditis
• Pericardial effusion
• Cardiac tamponade 

Exercising causes an increase in heart rate. This is in order to deliver blood around the body to meet the oxygen demands of the respiring tissue. However, this increase in heart rate adds stress to the heart and pericardium, causing inflammation to worsen. 

For athletes, a minimum period of three months without competitive activities is recommended, although the duration will be dependent on the severity. 

This advice will continue until there are normal findings in the diagnostic tests or until the symptoms stop.⁶ 

It is important to consult with your doctor when resuming exercise to best manage the condition and prevent recurrent episodes or causing the symptoms to worsen.⁹ 

Treatment

The treatment options for pericarditis are dependent on both the type of pericarditis as well as the underlying cause, if known.

Firstly, it is important to treat the underlying cause, for example using antibiotics for a respiratory infection. 

For acute pericarditis, NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen are used for the majority of cases. They are good for reducing the inflammation present, hence making symptoms less severe. 

Primarily used in gout treatment, colchicine is a prescription medication that is sometimes used in conjunction with NSAIDs in treating acute cases of pericarditis.⁶ 

When contraindications to NSAIDs are present, or they have been unsuccessful in alleviating symptoms, a corticosteroid treatment may be used.

One of the biggest complications of pericarditis is pericardial effusion. This is excessive fluid that has built up in the pericardium causing the sac to press against the heart. This can then cause cardiac tamponade - the pressure of the pericardium on the heart does not allow the heart to fill fully so a lower volume is pumped out.

To compensate, the heart rate increases to ensure an adequate blood supply to the body. As a result, it also creates other symptoms in addition to those listed for pericarditis. These include:

• Shortness of breath
• Hyperventilation
• Fainting or lightheadedness as well as enlargement of the veins.

The treatment for this serious complication is a procedure called pericardiocentesis. This involves draining the extra fluid using a needle and catheter. Once the fluid is drained, the severity of symptoms tends to decrease quite a bit.¹⁰

A pericardial window is a surgical intervention in which a small part of the pericardial tissue is removed. This allows the sac to be drained. This procedure is much more invasive than a pericardiocentesis and has to be done under general anaesthesia.

Due to this, it tends to only be done when a pericardiocentesis was unsuccessful, or the fluid returned after the procedure.¹¹ 

Summary 

Pericarditis is the inflammation of the pericardium: the sac surrounding the heart that's preventing friction. It is caused by excess fluid entering the space. Pericarditis is diagnosed through different diagnostic tests.

Managing pericarditis involves resting and avoiding strenuous exercise until normal results, or until  symptoms have alleviated.

Treatment looks at the underlying cause of the pericarditis. It also involves the use of NSAIDs such as ibuprofen and aspirin. However, in some cases, a course of corticosteroids may be used instead. In more complex cases with pericardial effusion leading to cardiac tamponade, a surgical procedure known as pericardiocentesis is required.