Pericarditis: chest pain that subsides when bending forward - diagnosis and treatment in Tashkent

Other names: Перикардит, воспаление перикарда, острый перикардит, сухой перикардит, экссудативный перикардит, выпот в перикарде, тампонада сердца

Pericarditis is an inflammation of the outer lining of the heart, a thin two-layer sac within which the heart beats freely. Normally, there is very little liquid between its leaves, and they slide over each other silently. When inflamed, the leaves become rough and rub with each contraction - hence the pain and the characteristic noise that the doctor hears when listening. This disease has a feature that is rare in cardiology: the diagnosis is largely suggested by the patient himself, if he accurately describes how the pain behaves. It intensifies in a lying position and with a deep breath, but when you sit down and lean forward, it noticeably weakens. This does not happen either with a heart attack or with angina, and it is this detail that most often directs the diagnosis in the right direction. The second thing you need to know: in some patients, fluid accumulates in the pericardial cavity, and if there is a lot of it, it compresses the heart - a condition requiring emergency care.

🧾 МКБ-10: I30 🏥 Where it is treated: 6 It's easier to sit leaning forwardworsens with inhalation and lying downTamponade is an emergency

👨‍⚕️ Which doctor

Cardiologist

🔬 Diagnostics

ECG, EchoCG, CRP, troponin, chest x-ray

💊 Treatment

Anti-inflammatory therapy, colchicine, exercise limitation

📈 Prognosis

Favorable, but some patients have relapses

⚠️ At risk

Viral infection, autoimmune diseases, heart surgery, tuberculosis, kidney failure

⏱ When to see a doctor

If there is a drop in pressure, swelling of the neck veins and shortness of breath - immediately

🚨 See a doctor urgently

With these signs do not wait for a scheduled appointment — the condition requires emergency care.

Нарастающая одышка, невозможность лежать, вынужденное положение сидя с наклоном вперёд
Резкая слабость, холодный пот, падение давления, частый слабый пульс
Набухшие вены на шее и отёчность лица при одновременной бледности и похолодании конечностей
Боль в груди дольше 20 минут, не меняющаяся от положения тела, — необходимо исключить инфаркт
Высокая температура с ознобом на фоне уже установленного перикардита
Кровохарканье, потеря веса, ночная потливость и длительный кашель

What is the pericardium and why does it become inflamed?

The pericardium is a dense membrane surrounding the heart and large vessels at their base. It consists of two sheets, between which there is normally about 15–50 milliliters of liquid: this is enough for the sheets to slide without friction. The pericardium anchors the heart in the chest and limits its overextension. With inflammation, the fluid can either be absent altogether - then they talk about dry pericarditis with severe friction and pain - or accumulate in a significant volume, and then the pain usually decreases, but shortness of breath appears.

Viral infections are the most common cause, especially in young patients
Bacterial infections, including tuberculous pericarditis, which remains relevant in the region
Myocardial infarction: inflammation of the pericardium is possible both in the first days and several weeks after it
Heart surgery and chest trauma
Autoimmune diseases: systemic lupus erythematosus, rheumatoid arthritis, scleroderma
Chronic renal failure, especially with insufficient dialysis
Tumor processes and radiation therapy to the chest area
Hypothyroidism is a rare but reversible cause of fluid accumulation in the pericardium

In a significant proportion of cases, a specific cause cannot be determined, and such pericarditis is called idiopathic. In practice, this most often means an unrecognized viral infection, and treatment does not change for this. An extensive search for rare causes is not warranted in everyone, but only in cases of prolonged progression, repeated episodes, large volumes of fluid, high fever, or associated symptoms suggestive of systemic disease.

В условиях высокой распространённости туберкулёза перикардит с постепенным началом, длительной субфебрильной температурой, ночной потливостью, потерей веса и большим объёмом жидкости требует обязательного исключения туберкулёзной природы. Такой перикардит лечится принципиально иначе, и стандартная противовоспалительная терапия при нём не только неэффективна, но и может отсрочить правильный диагноз.

The nature of the pain is the main clue

Pain with pericarditis is most often localized behind the sternum or to the left, and can radiate to the neck, back, left shoulder and, quite characteristically, to the trapezius muscle - the upper edge of the shoulder closer to the neck. But more important than location is how the pain behaves. It is clearly related to breathing and body position, and this connection is so typical that it allows one to suspect the diagnosis even before the examination.

It gets worse when lying on your back and gets noticeably better when you sit and lean forward.
Intensifies with a deep breath, when coughing, when swallowing, when turning the body
Often sharp, stabbing, cutting, and not pressing, as with angina
Lasts for hours and days, and not 5–15 minutes, like an angina attack
Not directly related to physical activity: may appear at complete rest
Often accompanied by low-grade fever and general malaise
Often occurs one to three weeks after infection

From this picture follows practical advice that is worth remembering: when describing pain to the doctor, be sure to tell what happens when you change body position and when you take a deep breath. The phrases “it’s easier when I sit down and lean forward” and “it hurts more when I take a deep breath” carry more diagnostic information than a detailed description of the intensity of pain on a ten-point scale. At the same time, it is worth noting whether you slept half-sitting, because a forced position is also an important sign.

Боль в трапециевидной мышце — верхнем крае плеча у основания шеи — считается особенно характерной для перикардита и объясняется общей иннервацией перикарда и диафрагмы. Многие пациенты не сообщают о ней врачу, считая, что «просто продуло шею» и к сердцу это отношения не имеет.

How to distinguish pericarditis from a heart attack

This is the key question in the first hours, because the tactics for these conditions are fundamentally different. The situation is complicated by the fact that with pericarditis, troponin is also increased - if the inflammation affects the adjacent layer of the heart muscle, and then they talk about myopericarditis. Therefore, the distinction is made based on a set of characteristics, and this is done by the doctor, not the patient.

Характер и длительность боли: острая, зависящая от положения тела и дыхания, длящаяся часами — в пользу перикардита; давящая, сжимающая, длящаяся 15–30 минут, связанная с нагрузкой — в пользу инфаркта.
Реакция на положение тела: облегчение сидя с наклоном вперёд для инфаркта нехарактерно.
Шум трения перикарда при выслушивании — специфичный признак, но он непостоянен и может исчезать через несколько часов.
ЭКГ: при перикардите изменения обычно распространяются на большинство отведений, тогда как при инфаркте они соответствуют зоне поражённой артерии.
ЭхоКГ: наличие жидкости в полости перикарда подтверждает диагноз, а нарушение сократимости отдельной стенки указывает скорее на инфаркт.
Лабораторные показатели: выраженное повышение СРБ характернее для перикардита; значительное и нарастающее повышение тропонина — для инфаркта.

There is only one practical conclusion from this section, and it is more important than all the listed differences: if you have prolonged chest pain, you need to call an ambulance, and not try to figure it out on your own. Even an experienced doctor in some cases cannot distinguish between these conditions without an ECG and tests. Trying to “check” whether bending forward will make it easier, instead of seeking help, is a dangerous waste of time if we are really talking about a heart attack.

Существует отдельная форма — перикардит, развивающийся через несколько недель после инфаркта миокарда или операции на сердце. Он проявляется возвращением боли в груди, температурой и повышением воспалительных показателей и нередко воспринимается пациентом как повторный инфаркт. Это состояние имеет другую природу и лечится противовоспалительными препаратами, поэтому при возобновлении боли после перенесённого инфаркта важно не заниматься самолечением, а обратиться к кардиологу.

Pericardial fluid and cardiac tamponade

During inflammation, fluid can accumulate in the pericardial cavity. What matters is not so much its volume as the rate of accumulation: the pericardium is capable of stretching, but slowly. If the fluid arrives gradually, hundreds of milliliters can accumulate in the cavities without noticeable symptoms. If the accumulation is rapid, even a relatively small volume begins to compress the heart, preventing it from filling with blood. This is tamponade - a condition in which minutes count.

Increasing shortness of breath, which worsens while lying down and forces you to sit leaning forward
Severe weakness, dizziness, feeling of impending loss of consciousness
Drop in blood pressure, rapid and weak pulse
Swelling of the neck veins with pale, cold and damp skin
Feeling of tightness and heaviness in the chest, anxiety, restlessness
Swelling of the face and neck, enlargement of the liver and abdomen with slow accumulation of fluid
A noticeable weakening of the pulse during inspiration is a sign that a doctor identifies when measuring blood pressure.

Tamponade is an indication for immediate evacuation of fluid under ultrasound guidance, and this procedure quickly and radically improves the condition. That is why, when increasing shortness of breath appears against the background of pericarditis, you cannot wait for a scheduled appointment. Separately, it is worth mentioning the chronic version: with slow accumulation, fluid can be detected by chance on an echocardiogram in a person with minimal complaints. Such a finding does not always require a puncture, but always requires a search for the cause - from hypothyroidism and renal failure to tuberculosis and a tumor process.

Важное и неочевидное следствие: при подозрении на тампонаду мочегонные препараты противопоказаны, хотя интуитивно кажется логичным «убрать лишнюю жидкость». Сердце в этой ситуации и так плохо наполняется, а уменьшение объёма циркулирующей крови резко ухудшает состояние. Помощь заключается в удалении жидкости of перикарда, а не в её выведении почками.

Examination and treatment

The diagnosis of acute pericarditis is made by a combination of typical pain, ECG changes, a pericardial friction rub, and the presence of fluid on echocardiography—a few of these signs are sufficient. The treatment of most cases is simple and well-established, and the main mistake of patients here is not in the choice of drug, but in premature cessation of therapy.

ЭКГ — характерные изменения в большинстве отведений; запись повторяют в динамике, так как картина меняется по стадиям.
ЭхоКГ — обязательное исследование: выявляет жидкость, оценивает её объём и признаки сдавления сердца.
СРБ и СОЭ — подтверждают воспаление и служат ориентиром для длительности лечения: терапию продолжают до их нормализации.
Тропонин — оценивает вовлечение сердечной мышцы; при его повышении режим ограничения нагрузок строже и длительнее.
Рентген грудной клетки — оценивает лёгкие и тень сердца, помогает заподозрить туберкулёз и другие лёгочные причины.
Дополнительно при затяжном или повторном течении: обследование на туберкулёз, аутоиммунные маркеры, гормоны щитовидной железы, оценка функции почек, при необходимости КТ или МРТ.

The basis of treatment for acute viral and idiopathic pericarditis is anti-inflammatory drugs in a sufficient dose with a gradual reduction rather than withdrawal immediately after the pain disappears, plus colchicine, which is prescribed over a long course. It is colchicine that significantly reduces the likelihood of relapse, and this is one of the most convincingly proven effects in this area. Glucocorticoids have limited use: they quickly relieve symptoms, but increase the risk of recurrent episodes, so they are prescribed when standard therapy is ineffective or when the disease is autoimmune. Limiting physical activity is a mandatory part of treatment, usually until symptoms disappear and indicators normalize, and for athletes - for a longer period.

Самая частая причина рецидива — прекращение лечения сразу после того, как боль прошла. Воспаление в этот момент ещё сохраняется, о чём говорят повышенные показатели крови. Ориентиром для окончания терапии служат не самочувствие, а нормализация СРБ и решение врача, а колхицин принимается месяцами, даже когда никаких жалоб уже нет.

Relapses and life after pericarditis

Approximately every fifth patient develops a relapse after the first episode, most often in the first months. This does not mean that the treatment was incorrect or that the disease has become chronic forever: most recurrent pericarditis can be completely controlled over time, although this may require long-term therapy. Knowing a few simple rules significantly reduces the likelihood of a repeat episode.

Do not stop treatment on your own when the pain disappears - reduce the dose gradually and according to the schedule
Undergo control tests before ending therapy, and not focus only on how you feel
Observe the load limit for the entire assigned period; for athletes - before the follow-up examination
If chest pain returns, contact a cardiologist immediately, rather than wait until it goes away on its own.
Treat infections in a timely manner and do not carry them on your feet
If there is a concomitant autoimmune disease, keeping it under control - this directly affects the risk of relapse
Inform any new doctor about pericarditis: this changes the interpretation of future chest pain and ECG data

A rare but serious long-term complication is constrictive pericarditis, in which the membrane becomes dense, thickened and stops stretching, squeezing the outside of the heart. It develops months and years later, more often after tuberculosis, bacterial or radiation damage, and is manifested by increasing shortness of breath, swelling, enlargement of the abdomen and liver. This condition is treated surgically. With ordinary viral pericarditis, the likelihood of such an outcome is very low, and this is another argument in favor of establishing the cause in a prolonged course, and not limiting ourselves to symptomatic treatment.

Полезная деталь для будущего: изменения на ЭКГ после перенесённого перикардита могут сохраняться неделями и месяцами. Если врач, впервые видящий такую плёнку и не знающий истории, оценит её как признак острого состояния, это приведёт к лишним исследованиям и тревоге. Поэтому имеет смысл сохранять копии своих кардиограмм и заключений и показывать их при каждом новом обращении.

Frequently asked questions: Pericarditis

How can you tell if chest pain is due to pericarditis?+

The most characteristic symptom is the dependence of pain on the position of the body: it intensifies when lying on the back and with a deep breath, and when sitting and bending forward, it noticeably weakens. The pain is usually sharp, lasts for hours, and often occurs one to three weeks after the infection. But the diagnosis can only be confirmed with the help of an ECG, echocardiography and tests, so if you have prolonged chest pain, you need to call an ambulance.

Is pericarditis dangerous?+

Most cases of viral and idiopathic pericarditis progress favorably and resolve completely with treatment. The danger is created by two situations: the rapid accumulation of fluid with the development of cardiac tamponade, requiring emergency care, and specific forms - tuberculous, purulent, tumor. That is why increasing shortness of breath due to pericarditis requires immediate attention.

How long does the treatment last?+

Anti-inflammatory therapy is usually continued until symptoms disappear and inflammation levels in the blood normalize, followed by a gradual reduction in dose, and colchicine is prescribed for several months. Stopping treatment immediately after pain disappears is the most common cause of relapse, so you need to focus on tests and the doctor’s decision, and not on how you feel.

Is it possible to exercise if you have pericarditis?+

In the acute period, physical activity is excluded. A return to them is possible after the disappearance of symptoms and normalization of inflammatory parameters, and if the heart muscle is involved, the period of restriction is significantly longer. Athletes usually require follow-up testing, including echocardiography and rhythm monitoring, before being allowed to train.

Can pericarditis recur?+

Yes, relapses occur in approximately every fifth patient, most often in the first months after the first episode. A full course of colchicine, a gradual rather than abrupt cessation of anti-inflammatory therapy, and adherence to an exercise regimen help reduce their likelihood. With repeated episodes, a more thorough search for the cause is required.

Is it always necessary to pump out fluid from the pericardium?+

No. A small to moderate volume of fluid in the absence of signs of cardiac compression usually resolves with anti-inflammatory treatment, and puncture is not required. Fluid evacuation is performed in case of tamponade, with a large volume of effusion, and in cases where it is necessary to examine the fluid to determine the cause - for example, if tuberculosis or a tumor is suspected.

The information on this page is for reference only and does not replace a doctor consultation. Only a qualified specialist can make a diagnosis and prescribe treatment after an in-person examination.

Where it is treated pericarditis в Ташкенте

В отличие от большинства сердечных болей, боль при перикардите напрямую зависит от положения тела, и одно это наблюдение пациента нередко экономит врачу несколько шагов в диагностике. Приём кардиолога, ЭКГ, ЭхоКГ и обследование при боли в груди в Ташкенте: