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Pericarditis
A stabbing that is worse lying down and better leaning forward — and colchicine over months is the part that prevents relapses.
Also known as: pericarditis · inflammation of the pericardium
Open in the tool — with search and all the links →This compilation is for information and replaces neither medical diagnosis nor treatment. If you have symptoms, see a doctor.
An inflammation of the sac in which the heart sits. It is one of the few chest pains that can almost be recognised from the description: sharp, often sudden, clearly worse lying down and on deep breathing, and noticeably better sitting up and leaning forward. That dependence on position is the hallmark and separates the pain from a heart attack, which is unimpressed by posture. It often radiates to shoulder or neck. Usually a viral infection comes first; autoimmune disease, a heart attack, surgery, kidney failure and other causes also occur. The treatment is unspectacular and effective: anti-inflammatories at an adequate dose, plus colchicine over months, which makes relapses markedly rarer — and it is precisely this second medicine that is most often left out. Also important is the fluid in the sac: if a lot collects, it can squeeze the heart. Breathlessness, distended neck veins and a fast, weak pulse are then the signs that allow no time to think.
Too low a dose and stopped too early is the commonest reason for relapse. Stopping follows the CRP, not the feeling.
The part most often missing. It roughly halves relapses and belongs from the start — ask for it if it was not prescribed.
It shows how much has collected and whether it is squeezing the heart. With a lot of fluid it is rechecked, not left.
Weeks with the sac alone, considerably longer if the muscle is involved. The troponin decides which case it is.
The neighbour of this condition — the two often run together, and then the stricter rules apply.
Anti-inflammatories take the pain away within days. Colchicine is the part that decides recurrence: taken over three months it halves the return — and it is exactly this drug that is most often stopped too early, because the pain is long gone. Cortisone helps quickly and raises the relapse rate; which is why it comes third.
The pain is better sitting up and leaning forward and worse lying down — that positional pattern is the identifying mark. About eighty to ninety out of a hundred cases are viral or without a graspable cause. Recurrence affects about one in three without colchicine, about one in six with colchicine over three months. Sport is paused for three months; in competitive sport until inflammation markers and ECG are normal.
That is the hallmark. Having to sit up at night to bear the pain is almost the diagnosis itself.
Deep breathing and coughing make it worse. Heart attack pain is dull and pressing and is unmoved by breathing.
One or two weeks earlier a cold or stomach bug — the same sequence as with myocarditis.
Between a fifth and a third have a relapse — mostly those treated too briefly or without the second medicine.
Increasing breathlessness, distended neck veins, a fast weak pulse: then fluid in the sac is pressing on the heart. That is an emergency.
Here more than a side value: it confirms the inflammation and afterwards guides how long to treat.
If it is raised the heart muscle is involved too. That changes the assessment and brings rest into play.
Advanced kidney failure is a cause in its own right and belongs checked once.
They lower the blood fats and act on the excitability of the heart muscle. Oily sea fish twice a week is the best-supported route; very high doses from capsules are not a harmless more.
Keeps the rhythm steady and lowers blood pressure. Water tablets drive it down, certain blood pressure drugs and a weak kidney drive it up — which is why it is checked under treatment.
A lack favours extra beats and at the same time keeps a potassium deficiency going. Anyone replacing only the potassium sees no success while the magnesium is missing.
Less salt lowers blood pressure measurably, and most of it is not in the salt cellar but in bread, cheese, cured meat and ready meals. With very low blood pressure the opposite applies.
In about one in three it comes back, and the commonest reason is that the treatment was ended too early. Colchicine over three months halves those relapses — that is one of the clearest numbers in heart medicine and the reason why the duration matters more than the dose.
As with the heart muscle: physical rest until the inflammation values are normal and the complaints are gone — in athletes three months is the usual frame. Starting again too early is the second commonest reason for a flare-up.
Not studied here, and the reason is worth having: the inflammation of the heart sac responds to anti-inflammatory medicines within days — that is an order of magnitude a dietary measure does not reach into. Sensible as long-term company for the heart, not for this flare.
Effective when deficient; effects on sleep and stress plausible but moderate. Too much causes loose stool.
Cortisone eases quickly — and markedly raises the relapse rate. This is why anti-inflammatory painkillers plus colchicine are the first route, and cortisone stays for the cases where that is not possible. A clear example: fast relief and a good course are not the same thing.
A pronounced underactive thyroid can itself cause fluid around the heart — it goes with treating the thyroid. With an effusion and no explanation TSH belongs in.
If fluid gathers in the pericardium salt is limited — about 5 g a day. Daily weight at the same time gives the fastest sign of retention.
Here too exertion is paused until inflammatory markers are normal — usually some weeks to months. Then a stepwise build-up.
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