Introduction to pericarditis

Have you or a loved one recently been diagnosed with pericarditis? You have had the consultation with your doctors but you still have doubts? Maintaining your heart health with medicines and lifestyle changes is key to managing this treatable condition. Let us try to unveil this diagnosis and some of the more concerning symptoms that might occur.

A thin, sac-like membrane called the pericardium lines our heart. Pericarditis occurs when this membrane gets inflamed due to various causes such as

• Viral or bacterial infections 
• Autoimmune disorders
• Complications of a heart attack 

The most common symptom is usually a sharp or dull pain in the middle of the chest. This pain can worsen when moving, breathing in deeply or lying down. Other symptoms may include fever, fatigue, and a general feeling of discomfort.^1,2

What is pulsus paradoxus?

One of the more “paradoxical” phenomena that can occur with pericarditis is pulsus paradoxus. Sometimes while taking a deep breath, individuals with pericarditis can experience a drop in blood pressure. The pulse feels feeble and the person may feel faint. This is because the inflamed pericardium will disrupt the heart's ability to pump blood at that moment. This results in a decrease in pulse strength.¹

Our lungs are very close to the heart, and when we breathe in, they expand. Under normal circumstances, there is minimum change in heart function when the lungs expand. However, if the pericardium is swollen, the lungs will exert pressure on the heart when they expand. This pressure on the heart results in a weaker contraction of the heart muscles, reducing the blood flow (and the blood pressure) for that moment.¹

Pericarditis with pulsus paradoxus is a medical emergency. Some symptoms requiring an urgent trip to the A&E include:

• Dull or sharp chest pain when moving
• Severe chest pain and discomfort
• High fever
• Feeling dizzy or passing out

Causes and mechanisms of pericarditis

So what causes the inflammation in the pericardium? There are three major causes: infections, autoimmune processes and a complication of heart attacks. Heart attacks are also called myocardial infarctions.³

• Infections: Infections can be viral or bacterial. Pathogens affect the cells of the heart and can cause an immune response by the immune system. This immune response triggers irritation and subsequent swelling. Bacterial infections can also cause the collection of infected fluid in the gap between the layers of the heart. This is called pericardial effusion and constitutes a medical emergency
• Autoimmune disorders like rheumatoid arthritis and systemic lupus erythematosus can trigger inflammation as well due to exaggerated immune responses throughout the body
• Sometimes, pericarditis is a complication of heart attacks/myocardial infarctions

Sometimes the immune processes involved with inflammation can result in the fluid collecting in the pericardial sac. This condition is called pericardial effusion, which further impedes heart function by compressing the heart.³

This compression of the heart becomes even worse when we breathe in. Usually, severe cases of pericarditis can result in the weakening of the pulse and a drop in blood pressure when inhaling. This is also known as pulsus paradoxus.³ 

Diagnosis of pulsus paradoxus

Making the diagnosis of pulsus paradoxus requires comprehensive analysis by a team of doctors including cardiologists, internal medicine specialists and radiographers.

1. Clinical assessment: Your doctor will first take a detailed history of your medical symptoms, previous illnesses and your current symptoms. This will allow them to determine what may be the underlying causes behind your symptoms. Then they will examine you, conduct a physical assessment, and listen to your heart with a stethoscope to diagnose the condition. Pulsus paradoxus is usually diagnosed while measuring your blood pressure and listening to your heart and pulse
2. Tests: The doctors will further understand the electrical activity and condition of the heart through an electrocardiogram (ECG). Lab tests may be conducted to assess the health of the heart muscle. Imaging tests such as an echocardiogram are used to visualise the heart and surrounding tissues and understand the extent of inflammation. It can also help clinicians understand the amount of pressure on the heart and the changes to the blood flow
3. Further tests: Sometimes further tests such as MRIs or cardiac catheterisation may be conducted in case of complex cases or inconclusive results. This can help understand the causes of the symptoms and treat them accordingly⁴

Treatment options of pericarditis with pulsus paradoxus

Managing pericarditis with pulsus paradoxus involves a multifaceted approach including medicines, procedures, lifestyle modifications and regular follow-up and monitoring. You will be advised to avoid strenuous activity, rest as much as possible and apply cold or warm compresses in areas of discomfort.

1. Medical management: Medicines are prescribed to reduce inflammation and ease discomfort. Corticosteroids may be prescribed in severe cases
2. Procedures: In case of pericardial effusion (fluid collection in the pericardial sac), the fluid may be drained by a procedure called pericardiocentesis
3. Monitoring and follow-up: Evaluating the condition during treatment is vital. This is usually done via blood tests and assessment of the various conditions by the clinician⁵

FAQ’s

Can pericarditis be prevented?

While pericarditis can occur spontaneously, certain measures can help reduce the risk of recurrence. Maintaining a healthy lifestyle, managing underlying medical conditions effectively, and avoiding triggers such as viral infections or autoimmune flare-ups can contribute to prevention efforts. 

What are the long-term effects of pericarditis?

In most cases, pericarditis is resolved with appropriate treatment and does not lead to long-term complications. However, recurrent episodes of pericarditis can increase the risk of complications such as pericardial effusion, constrictive pericarditis, or cardiac tamponade. These complications may then require further intervention. 

Can pericarditis lead to heart failure?

Pericarditis itself does not typically lead to heart failure. However, complications such as pericardial effusion or constrictive pericarditis can impair heart function and contribute to heart failure symptoms. Prompt diagnosis and management of pericarditis can help prevent such complications. 

Are there any dietary restrictions for individuals with pericarditis?

There are no specific dietary restrictions for individuals with pericarditis. However, adopting a heart-healthy diet rich in fruits, vegetables, whole grains, and lean proteins can promote overall cardiovascular health. Limiting salt intake may be advisable in cases of pericardial effusion to reduce the build-up of fluid. 

Is pulsus paradoxus always present in pericarditis?

Pulsus paradoxus is a clinical finding associated with pericarditis but may not be present in all cases. It depends on the severity of pericardial inflammation and its impact on cardiac function. Healthcare providers may look for pulsus paradoxus during physical examination. However, its absence does not rule out the diagnosis of pericarditis.

Can pericarditis reappear after successful treatment?

Yes, pericarditis can reappear even after successful treatment, especially in case of viral pericarditis or pericarditis with an unknown cause. Recurrent pericarditis may require prolonged or maintenance therapy. 

Is pericarditis a life-threatening condition?

Pericarditis is typically not life-threatening, especially when promptly diagnosed and managed. However, complications such as cardiac tamponade or constrictive pericarditis can be life-threatening if left untreated. Seeking medical attention for symptoms of pericarditis is essential to prevent potential complications.

Are there alternative therapies or complementary treatments for pericarditis?

Conventional medical therapy remains the mainstay of treatment for pericarditis. However, some individuals may explore alternative or complementary therapies such as acupuncture, herbal supplements, or dietary modifications. It is essential to discuss these options with a healthcare provider to ensure safety and efficacy. 

Can pericarditis affect individuals of any age?

Pericarditis can affect individuals of any age, although it is more commonly seen in adults. Viral infections are a common cause of pericarditis in younger individuals. In contrast, autoimmune disorders and underlying medical conditions may predispose older adults to pericardial inflammation.

Summary

• Pericarditis is a heart condition involving swelling of the membrane surrounding the heart
• Pulsus paradoxus is a phenomenon that occurs with pericarditis. It involves an abnormal drop in blood pressure while breathing in due to the compression of the heart
• Some symptoms of pulsus paradoxus include dizziness, fatigue, passing out or feeling faint, feeble pulse and a general feeling of discomfort
• The condition is diagnosed by a thorough clinical examination, blood tests, ECG, echocardiogram and sometimes MRIs or cardiac catheterisation
• Management includes painkillers, steroids in severe cases, and monitoring. Sufficient rest and reduced physical activity are recommended