Pericarditis: Symptoms and Screening

Cardiologists Allan Klein, MD, and Deborah Kwon, MD, explain what pericarditis is and the key symptoms that come with it. They discuss the how the condition is diagnosed and the range of treatments that can help people recover and reduce the risk of recurrence.

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Transcript

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Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Allan Klein, MD:

Hello, I'm Dr. Allan Klein from Cleveland Clinic. I direct the Pericardial Center, and with me is Dr. Debbie Kwon. Debbie, tell me about yourself.

Deborah Kwon, MD:

Yes, my name is Debbie Kwon. I'm a cardiologist at Cleveland Clinic as well and had the pleasure of being able to work with Allan in the Pericardial Center. I'm also the Director of Cardiac MRI at Cleveland Clinic.

Allan Klein, MD:

Our listeners want to hear about pericarditis. What is pericarditis? And maybe, I can just ask you what should we tell patients about pericarditis versus a heart attack?

Deborah Kwon, MD:

Yeah, that's a great question. Oftentimes, it can be very difficult for patients to tell the difference between the two. Pericarditis is actually inflammation of the lining surrounding your heart. The heart sits inside of a sac, if you will. That sac can get inflamed, and then it can feel like chest pain. This is different from a heart attack, which is chest pain because there's not enough blood supply to the muscle tissue that results in pain.

Allan Klein, MD:

If I may say, the cause of pericarditis is often after a virus. I would say 80% is after a viral infection. You get the flu. You get a cold, rhinovirus. It could be even COVID. It inflames the sac around the heart. Another leading cause is post-cardiac injury from procedures. If you have, for example, an afib ablation, even post-valve surgery can cause it as well. Then, there's another type, what you call autoimmune, like lupus and rheumatoid, can cause that as well. But by far, it’s the viral infection. We call that autoinflammatory disease versus autoimmune.

Deborah Kwon, MD:

How would you describe to the patients how they might recognize that they may have pericarditis? What kind of symptoms might they have?

Allan Klein, MD:

We are involved with the guidelines, and there's some new criteria. The classic symptom would be sharp pain when you take a deep breath. You almost bend forward, like in the fetal position. If you lie back, it'll be very, very severe, and you have to sit forward. Very sharp pain, always going to the left shoulder, because of the innervation of the nerves. Then, often in the testing, you'll hear a rubbing sound when the doctor examines the patient, you hear a scratchy sound. The EKG almost looks like a heart attack, a little bit different. If you do the ultrasound, echocardiography, you'll find a lot of fluid around the heart.

Then there are some special tests. Some blood tests called CRP, C-reactive protein, which often, obviously, goes up. It starts off around less than one, it goes up to 50, in the bad cases. MRI, especially MRI, now, we have an imaging biomarker, and you know a lot about MRI. Maybe you could just say what you find on an MRI in these patients.

Deborah Kwon, MD:

Yeah. Yeah, definitely. I think MRI has really come onto the stage a lot from the research that you've been doing, Allan, to help us really understand pericarditis, and how to treat pericarditis. I think that it's important for patients to know that the initial testing is EKG, echo and blood work. Oftentimes, the treatment is colchicine, aspirin or ibuprofen. Typically, I'd say maybe 80% of the time, that's enough. But in patients who continue to have chest pain, or there's some uncertainty about the diagnosis, or there's a complication on the imaging with echo that suggests there's maybe more high-risk features, cardiac MRI can be very helpful. That allows us to directly identify the inflammation around the heart, and also quantify the amount of inflammation around the heart, so that it can guide the treatment of how intensely we should be ramping up the medications.

Allan Klein, MD:

Yeah. I would like to reiterate that not everybody needs an MRI, but for the standard cases, we often do take a good history. The blood tests are important. Ultrasound may be important. For complicated cases, people that have a lot of recurrent episodes, perhaps MRI would be very useful. Also, a lot of people have different types of pain, and not everything is even the heart. It's a good way to exclude active pericarditis. 

There’s a lot of new treatments. You're alluding to a few treatments. As Dr. Kwon mentioned, the standard therapy, first-line would be NSAIDs, ibuprofen or aspirin. Aspirin in older folks, people with coronary artery disease. Then, you have colchicine, a medicine that you give for gout. It can be used as well.

Another big thing is exercise restriction. We tell people to keep their heart rate less than a hundred when they're very active, and gradually they can increase. 

In the past, as you know, the traditional therapy was steroids, low-dose steroids. But now, with the newer guidelines, we're bypassing that, and going right to what you call IL-1 blockers. Maybe you can mention what IL-1 blockers are, and what's available now for patients out there.

Deborah Kwon, MD:

Yeah. Interleukin is something that is stimulated, if you will, by the inflammatory pathway. Patients with severe pericarditis can have this very much ramped up. Therefore, there have been medications that have been developed recently that have been very effective in blocking that pathway. It decreases the amount of inflammation. Dr. Klein has been very instrumental in really demonstrating the amazing effectiveness, particularly, with rilonacept. It's an injectable medication that you take once a week. It is more of a stronger anti-inflammatory. We call it a biologic, and so, it actually suppresses your immune system. We don't like to use it as a first-line therapy, because it can have other side effects. We have to monitor many things, in terms of your liver enzymes, your lipid profile, your cholesterol, et cetera. But it's very effective for patients who otherwise have refractory pericarditis.

Allan Klein, MD:

Yeah, that's a great therapy. But I should mention that acute pericarditis is when you have these classic symptoms. They last roughly four to six weeks, and most people will do well. They'll go to the ER, and they won't have any other episodes with proper therapy. Then, we have other things called recurrent pericarditis, where it gets better for four to six weeks, and then all of a sudden, it comes back. That's recurrent. Another type would be a little more aggressive, incessant. Meaning, nonstop for those first three months, you don't get a break, you still feel the pain. Then, after three months, we call that chronic. Those are some of the definitions we use out there.

Another thing I'd like to emphasize is that if you don't treat the first one well, it's going to come back. That's the most common cause of recurrence, under treatment of the first episode. I think the field's made a lot of advances. We talk about pericardial disease centers, I think. Cleveland Clinic has one. Maybe we're the first one to have that. Maybe you could tell us about our Pericardial Disease Center. How does that run? How do we get patients and how do we take care of them?

Deborah Kwon, MD:

Yeah. I think that pericarditis has become a very hot field as many people are starting to recognize that this may be an underdiagnosed entity. Many patients are actually actively involved in patient groups with Facebook. I think there's a Pericarditis Alliance also, where it's a fantastic resource for patients to connect with each other, learn about what other centers are doing, where the other centers are. In fact, yesterday, I saw a patient from Georgia, and she said that there was no pericardial center in Georgia. I think patients are really looking for centers that have this kind of expertise, and seeing patients with recurrent pericarditis that are not able to get the resolution with the typical type of treatment. [MB1] Allan has again been the pioneer in developing our pericardial center. I don't know, how many years has it been now?

Allan Klein, MD:

Well, we've been doing this for 10, 15 years. But I would say, in the last five, six years, we've really organized it well. We have a nurse practitioner who's our coordinator. We have a lot of team members who see these patients. We have referrals to surgery. We have surgeons. We have rheumatologists. We have advanced imaging. We talked about MRI, echocardiography. We can send them to the cath lab, if we want to measure pressure. We have really one-stop-shopping. Patients often stay for one to two days to get all the testing. We plan some of the testing in advance. Then, we have a very good follow-up. After the first visit, we often do a follow-up with the nurse practitioner to see how they're doing. Then, they come back roughly every six months to a year. We do some testing to see if it's improving, and we follow them for, actually, several years. Now, recurrent pericarditis becomes a chronic disease, and they keep on coming back. Would you say you see that in your practice?

Deborah Kwon, MD:

Yes, definitely. Definitely. I think it's probably one of the most rewarding things, when we see a patient who had such severe symptoms, and then we're able to treat them through it. Then, they finally get their quality of life back, it resolves. Then, they're able to do the things that they weren't able to do for so long because of pericarditis. I think, as a physician, you probably may feel the same way, that it's very rewarding when we can see the patients get back to the quality of life that they had missed for so long. One of the questions that I frequently get is, how do we know if their pericarditis is going to recur again? Allan, maybe you could speak to that. You developed a “Klein score” to help predict these things.

Allan Klein, MD:

So, like different scores, there's something for atrial fibrillation called CHA2-DS2-VASc. Now, there's a Klein score. I didn't know they were going to name it that way, but there is such a score. We can come up with some parameters. Actually, artificial intelligence helped us create some of these parameters. We came up with a top 10 list. If you have a lot of these bad parameters, for example, if you have many episodes, and if it keeps on coming back, it's autoimmune, if the MRI is very hot looking, if you're on steroids, a fast heart rate, a very strong ejection fraction. 

You add all these parameters up, and if you have a high score of more than seven, that's a high risk to not get better, a low risk to get remission. If you add them up, and it's a low score, less than four, we call it a green light versus a red light. Green light, it's a very good remission rate, more than 80%. In between would be orange.  We often look at their first visit here, and we try to add up these parameters, and we can predict. 

We mentioned MRI. MRI, in Dr. Kwon's hands, gives us a lot of information from that first visit, and we see what looks like a halo sign. We call that a halo sign, very active inflammation. We can predict this could be more than a year, it could be up to three to five years. We know from the first picture, that this is an aggressive case. Not every case is like that, but often this is. It is a chronic disease. It does get better, but just takes a lot of time. You have to have a lot of patience. 

The exercise part is very crucial, because a lot of our patients are in their 30s and 40s. Often, they like to go to the gym. If you go to the gym, and work out and have a fast heart rate, it's just going to recur. We try to calm it down, and perhaps some of the newer medicines, you can exercise, and we're studying that as well.

So, this is fascinating, because I think pericarditis is not well understood. It's misrepresented, or underrepresented. Obviously, a heart attack may be more serious, but with this, there's a lot of morbidity, a lot of pain, a lot of suffering. Patients have trouble finding the right doctor, the right center. As you mentioned, your patient from Georgia, they're going to ERs. They're being sent home, undertreated. Keeps on coming back, and by the time we see them, it's been a year or two sometimes. The important message, if you catch it early, and you go on the right medicines, and you take them for long enough, and you taper slowly, perhaps you can beat this thing.

Deborah Kwon, MD:

Yes, yes. I think also, some things that are very helpful for the recurrent pericarditis, as you had mentioned, is the cardiac MRI. That can be helpful, also for the doctor to decide when to institute the biologic. When is it okay to taper? But we've also noticed that the patients really like to see the MRI, too. It brings a lot of confidence when they see that they're being treated, and they, themselves, can visually see that the amount of halo sign around the heart is decreasing at each time. Then also, when you see that it actually goes away completely, it gives them a lot of confidence. They think that their treatment is working, and that they can go forward with less anxiety about when is this potentially going to recur. I know, Allan, you show your patients their MRIs frequently during their clinic visit.

Allan Klein, MD:

They often take their cell phone out, and they take a picture of how it started, how severe it was. Over time, it gets better, and a lot of confidence. At Cleveland Clinic with our Pericardial Center, we sometimes, if it doesn't work over many years, we often refer them to surgery. We call that pericardiectomy, where we remove the whole lining, and we have some excellent surgeons that can help with that, and patients do well with that. We have the medical therapy. We have the surgical therapy. We have it all covered here at Cleveland Clinic. Thank you, Dr. Kwon. Thank you to the audience for listening to the Love Your Heart podcast. Thank you so much.

Deborah Kwon, MD:

Thanks so much.

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