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When a patient comes to us with symptoms of chest pain and shortness of breath, they’re usually worried that they’re having a heart attack. While ruling out a heart attack based on imaging and blood tests can give patients a feeling of relief, their doctors could still be missing a potentially serious condition called pericarditis.
Pericarditis occurs when the pericardium, a fluid-filled membrane around the heart, becomes inflamed, or swollen and irritated with inflammation. Left untreated, pericarditis can cause significant chest pain and pericardial effusion, which is excess fluid buildup that puts pressure on the heart and can be dangerous. Pericarditis may also cause problems with heart rate and rhythm, often leading to a condition referred to as atrial fibrillation.
It’s tricky to spot pericarditis before it progresses. More than 80% of cases in the U.S. don’t have an identifiable cause, meaning inflammation affecting the heart likely started in response to a virus that the body has already eliminated. In other cases, autoimmune conditions—such as lupus, rheumatoid arthritis, or cancer may also lead to pericarditis.
MedStar Washington Hospital Center and MedStar Heart & Vascular Institute have the most sophisticated and cutting-edge modalities to diagnose and treat pericarditis. If we can identify and treat it early, we can potentially decrease severity, complications, and even its risk of recurring.
About 15-30% of patients will develop pericarditis again later. Each recurrence increases the risk of debilitating symptoms such as:
- Feeling generalized weakness
- Chest pain which may get worse with lying flat and improve with sitting up
- Skipping, slowing, or racing heartbeat
- Shortness of breath
- During late stages, stiffening of the pericardium can restrict the pumping function of the heart and lead to swelling of abdomen and legs, called constrictive pericarditis
- Cardiac tamponade, pressure around the heart caused by pericardial effusion
Currently, treatments for recurrent pericarditis include medications which reduce inflammation around the heart. During advanced stages or refractory disease however, patients may require an invasive surgery. We are working to change that problem by hosting a multicenter clinical study of a new Cannabidiol derivative that may help reduce inflammation, relieve symptoms, and potentially reduce the risk of future episodes.
Related reading: Managing pericardial disease: A changing paradigm (Cardiovascular Physician magazine)
How we diagnose pericarditis.
Once we rule out a heart attack, it is investigation time. We backtrack through a patient’s health history like detectives to understand:
- When symptoms started
- Other symptoms that seem unrelated to the heart, such as a cough or fever (possible signs of infection)
- Whether they've had these symptoms before
- If their symptoms point to reduced blood flow, such as shortness of breath, fatigue and weakness, or acute chest pain
The doctor may order an MRI and echocardiogram of the heart, along with an EKG to measure the electrical activity in your heart. Our cardiac imaging team performs and interprets more than 4,000 cardiac MRI and CT images each year—this team of experts understands the nuances that identify pericarditis to provide a streamlined diagnosis.
We will also order blood tests for two inflammatory markers: sedimentation rate (ESR) and ultra-sensitive C-reactive protein (CRP). High levels of these markers may suggest pericarditis and the need for swift treatment, especially if other symptoms are present.
One note: Fluid around the heart is often found by chance while a patient is getting imaging for something else, like the lungs or the spine. This is what’s referred to as “incidental finding”. If there are no symptoms, the fluid likely isn’t a sign of pericarditis and won’t necessarily need treatment.
Treatment options for pericarditis.
MedStar Washington Hospital Center offers the most advanced diagnostic imaging, such as echocardiography, cardiac MRI, and CT. We also possess the expertise to provide advanced medications and surgery, when necessary.
First-time pericarditis.
Colchicine is the frontline treatment for first-time pericarditis, along with nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. Colchicine is an anti-inflammatory medication that has been used for other inflammatory conditions, such as gout. Together, colchicine and NSAIDs can effectively control pericarditis symptoms and help reduce the risk of it coming back.
About 15-30% of patients will get pericarditis a second time. The second case and beyond will likely be more severe and will increase the risk of chronic, potentially debilitating symptoms. Patients who get it a second time have a 50% risk of developing it a third time. The more times you have it, the more severe and lengthy each case typically becomes.
Many patients may develop pericardial effusion (or fluid around the heart) during their pericarditis episodes. When the size of this fluid or effusion is large and when it builds up quickly, it the ability of the heart to fill with blood can be restricted. This may necessitate a procedure called “pericardiocentesis”, which drains that fluid around the heart.
Under ultrasound guidance, a cardiologist may consider draining this fluid by positioning a fine needle into the pericardium. Then we attach it to a drain that stays in place for a few days until the fluid volume normalizes. We typically only perform this procedure as a lifesaving measure or to test the fluid for cancer cells etc., because disturbing the pericardium can itself initiate or worsen inflammation.
Recurrent pericarditis.
Colchicine and ibuprofen typically are not enough to control symptoms in recurrent pericarditis. There are a few injectable medication options to consider:
- Rilonacept is a weekly injectable. It is the only recurrent pericarditis medication approved by the U.S. Food and Drug Administration (FDA).
- Anakinra is a once-or-twice daily injectable medication traditionally used for conditions such as rheumatoid arthritis. Though it is not FDA-approved for pericarditis, it is an alternative that can help patients.
- Corticosteroids can help reduce symptoms but can increase the risk of recurrence and cause side effects expected with steroids such as weight gain, sleep disturbance, and skin changes.
Taking injections may be a problem for some patients, and once a patient stops taking the medication, they may be at risk of recurrence.
Our clinicians and researchers are always seeking better ways to manage recurrent pericarditis and prevent future episodes. Participating in clinical trials is a safe, effective way to explore new medication options.
Clinical trial to study a cannabinoid oil derivative.
The MAvERIC Trial is a phase 2 study enrolling patients at MedStar Washington Hospital Center and health centers throughout the U.S. Our goal is to learn whether CardiolRX™, an oral medication that may be easier to take than an injection, will be helpful in treating pericarditis.
Cannabidiol (CardiolRx™) is an oral solution which has been found in animal studies to reduce multiple inflammatory signaling pathways, which are known to play crucial role in pericarditis and myocarditis. This multi-center pilot study aims to evaluate the safety and tolerability of CardiolRx™ during pericarditis recurrence, while also assessing improvement in symptoms and weaning off other therapy.
After eight weeks of treatment, we will measure severity chest pain among patients in the trial based on an 11-point rating scale and check the CRP levels of their blood. Patients will subsequently receive another 18 weeks of treatment, at which time we will study whether patients can wean off other pericarditis medications, such as steroids. Patients across the sites are doing well so far—the clinical researchers meet monthly to discuss our findings.
To enroll, patients must be 18 or older with at least two episodes of pericarditis that cannot be explained by a condition such as rheumatoid arthritis or cancer. Other criteria include pericarditis-related pain or high CRP level. Patients may not join if they have certain diseases including cancer and sustained heart rhythm problems, have taken a cannabinoid within the past month, or are currently on an immunotherapy medication.
Participating increases our ability to treat recurrent pericarditis for patients who don’t fully respond to frontline therapies. This study could change the paradigm of pericardial disease from a chronic, debilitating condition to something that can be managed without invasive treatment—giving patients more and higher-quality years of life after pericarditis.
