Massive Chest Pain May Not Be Heart Attack

Pericarditis may feel like a heart attack
Asian man holding chest

Massive chest pain that feels like a heart attack might be something else:  acute pericarditis, a potentially life-threatening inflammation of the sac around the heart that causes the sac to become hardened and thickened — or possibly a more serious condition called constrictive pericarditis, in which the heart feels as if it’s being strangled.

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These pericardial clinical conditions may be due to a variety of reasons ranging from viral infections to the aftereffects of surgery, says Allan Klein, MD, Director of Cardiovascular Imaging Research and Director of the Center for the Diagnosis and Treatment of Pericardial Diseases at Cleveland Clinic. Doctors use magnetic resonance imaging (MRI), echocardiography, as well as inflammatory markers to gauge severity of the condition and appropriate therapy.

Post-procedural complications are a leading cause of constrictive pericarditis including those caused by radiation. “If you had Hodgkin’s disease 20 or 30 years ago, you could possible acquire pericardial heart damage from the radiation,” says Dr. Klein.

Pericarditis diagnosis can be tricky

With the pain of acute (less than 3 months) or recurrent pericarditis, Dr. Klein says that patients can be in the fetal position and unable to take a breath.  “The pain goes to the left shoulder, and they have to sit forward for relief.”

With constrictive pericarditis, patients have elevated veins in the neck as well as abdominal or leg swelling.  Dr. Klein indicates that the patients actually look like they’re pregnant. 

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Since its symptoms are similar to those of other cardiac and pulmonary diseases, pericarditis can be difficult to diagnose.  Dr. Klein recently worked with a group of experts to develop a new consensus statement for the American Society of Echocardiography to help physicians pinpoint the condition.  The report outlines evidence-based guidelines to help primary care doctors and cardiologists identify the condition.

Condition often recurs

More than one-third of patients with acute pericarditis end up with recurrent or relapsing pericarditis, in which “they’re stuck on the anti-inflammatories,” Dr. Klein says.  “Every time they try to taper the steroids, it comes back.  In most cases, it works to taper the medicine very slowly over many months; but there have been rare instances where surgery is recommended to treat the recurrent chest pain and complications of the medications.” 

Dr. Klein notes that pericarditis is an “equal opportunity disease” that can affect young people (even teenagers and college kids) as well as 60- and 70-year-olds.”  “It affects people who are professionals and people who are laborers.  I even had a high-schooler who had to miss a year of school.”

Sac removal is a last resort

A triple therapy of drugs including NSAIDs, prednisone and colchicine, work to reduce the inflammation and prevent the need for surgery.  In other cases of advanced constrictive pericarditis, full removal of the sac, known as a pericardiectomy, is performed.

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The heart sac helps protect the heart from infection but is not necessary to live; it primarily performs mechanical functions of protecting and limiting the expansion of the heart.  Dr. Klein states that when the sac is damaged and becomes pathologic, it becomes a liability. 

“If you don’t do a good job removing the sac, and it continues to harden, heart failure symptoms will increase.  Doctors are unsure of how to diagnose the condition, and the patients are desperate for treatment.”

Unlike many conditions, Dr. Klein adds, exercise is not recommended for acute or recurrent pericarditis sufferers when there is active inflammation.  “You don’t want to move around too quickly,” he says.  “Exercise is the worst thing; your heart muscle will keep hitting the sac and aggravate the condition.”

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