Dr. Jeff Hersh: When a heart attack is not a heart attack

Dr. Jeff Hersh

Q: I started having chest pain and thought I was having a heart attack. The nurse who did the ECG told me it was a heart attack, but the ER doctor told me I had an inflammation around my heart and only needed aspirin and to follow up with the cardiologist in the morning. What can cause this?

A: Pericarditis is inflammation of the pericardial sac that surrounds the heart. Although the overall incidence of this condition is unknown (due to mild cases not coming to medical attention), it is responsible for about 1 in 1,000 hospital admissions. It sounds like that is what you had; check with your doctor to confirm this.

Pericarditis causes chest pain that often worsens with a deep breath. The electrocardiogram (ECG) shows changes (ST elevations) similar to those seen in a heart attack, but in all regions of the heart as opposed to specific regions. On examination, the physician is often able to hear a rubbing sound from the heart moving within the inflamed sac. In fact, these are the criteria used to diagnose pericarditis. In addition, some pericarditis patients will have fever and possibly other symptoms.

There are many causes of pericarditis, although in up to 80 percent of cases no specific cause is identified (called idiopathic pericarditis). When a cause is identified, infections (most commonly from viruses, but bacteria or fungal infections can also be responsible), autoimmune diseases (lupus, rheumatoid arthritis, others), mechanical causes (trauma, after surgery or from radiation therapy done to treat some other condition), metabolic diseases (kidney failure, low thyroid, others), cancer, drugs or other causes may be implicated.

Once pericarditis is diagnosed, further evaluation is usually done. An echocardiogram (an ultrasound of the heart) is routinely used to look for fluid (effusion) in the pericardial sac and to determine how effectively the heart is pumping blood. A CAT scan or MRI may be done to determine the extent of pericardial involvement. Blood tests can evaluate cardiac enzymes and look for metabolic causes of pericarditis such as kidney or thyroid disease.

Although uncommon, if pus collects in the pericardial sac (purulent pericarditis), the disease is particularly severe with very high mortality; otherwise death from pericarditis is rare. However, there are other possible complications of pericarditis.

Significant amounts of fluid may develop in the pericardial sac in response to the inflammatory process. If this occurs, the fluid inside the sac can push against the beating heart, minimizing how effectively it can pump blood. This can create a situation where the body gets insufficient blood supply, causing many complications; thankfully this is not common. Constrictive pericarditis, where scarring can cause the sac to lose elasticity inhibiting the heart's ability to squeeze adequately, can also occur.

In about 15 percent to 30 percent of patients who develop pericarditis, the condition will recur. Although there is no way to know for sure which patients will suffer a recurrence, those who do not respond to initial treatments may be at higher risk. Recurrences usually occur within the first one to two years, although recurrences later than this are possible. Patients with recurrent attacks will typically have only one or two, but more and even chronic symptoms can plague some patients.

Patients at higher risk, such as those with more gradual onset of symptoms, high fever, large effusions or other factors (patients who are immune compromised, on anticoagulant therapy or had trauma cause their condition) are usually hospitalized. Non-high risk patients may be considered for outpatient treatment.

Since this is an inflammatory condition, it is not surprising that aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) are standard treatments. Several studies have supported adding colchicine (better known as a gout mediation) to other treatments, as this seems to significantly reduce the occurrence of recurrent disease. Although idiopathic and viral causes of pericarditis usually need only these treatments, patients with disease caused by other conditions (such a bacteria, cancer, etc.) will need treatment of their underlying condition.

Patients that do not respond to treatment and/or those that develop chronic pericarditis may require treatment with steroids. Surgery to remove the pericardial sac is sometimes considered, however since there is a fairly high rate of mortality from this and it often does not provide benefit for patients, it is usually only considered if medical treatments have failed.

So, although it is often good news when someone hears that their chest pain is from pericarditis and not a heart attack, appropriate treatment and close follow-up is very important.

Jeff Hersh, Ph.D., M.D., F.A.A.P., F.A.C.P., F.A.A.E.P., can be reached at DrHersh@juno.com.