RA doesn’t just affect joints. It can affect the lungs, kidneys, pancreas, and so on – all the body’s systems. That’s a problem with a systemic disease.
Although I had thought my disease was fairly well controlled, it turns out that even though my joints seem to be okay, and my labs look fantastic, there’s hidden inflammation wreaking havoc internally. In my ongoing learn-A&P-by-malfunction life-course, I now get to learn all about pericarditis.
Pericard-itis is exactly what it sounds like it would be: inflammation of the pericardium. And if you’ve ever taken Greek (thank you, Dr. Pecota), the pericardium is exactly what it sounds like it might be: peri is a preposition meaning around, and cardion means heart, so the pericardium means something around the heart. Thus pericarditis is inflammation of the thin, double-walled sac that surrounds the heart. And let me tell you, it hurts!
There are many potential causes of pericarditis, and one is autoimmune diseases like RA. Other causes include infection, heart attack/surgery, cancer, chest injury, HIV, and TB. But with RA/SLE/PsA as a risk factor, this is something that the autoimmune community really ought to know more about.
The main symptom is chest pain. This is most commonly sharp, stabbing pain – particularly in the center. If you’re atypical like me, it could be more of a dull ache. Think of your entire sternum hurting. If you have a history of costochondritis (inflammation of the joints where the ribs attach to the sternum), you might be tempted to dismiss pericarditis symptoms as a costochondritis flare. We’re talking about chest pain, though. Go see your doctor!
Other symptoms can include:
- Shortness of breath or difficulty breathing
- Pain when swallowing
It’s important to know the symptoms and seek help when warranted. Don’t blow this off as a minor flare. When we have chest pain, we need an accurate diagnosis and a good treatment plan!
Easier said than done. I ignored things for a couple weeks, until finally my family members were concerned and insisted that I see our doctor. Now, I like my doctor, but am not looking for extra excuses to see him. I tend to figure that if I ignore things long enough, they’ll get better on their own. After all, the body has a remarkable ability to heal itself! Nonetheless, to get family members off my back, I went to see my doctor. He is usually pretty good at the MD’s poker face. Nothing fazes him. But when we discussed the “what makes it better/worse” question and I told him that it helps to lean forward, he looked at me like I’d lost my mind. I smiled, “What can I say? I just report the symptoms. You get to figure out what they mean.” As it turns out, it’s pretty well documented that sitting up and leaning forward can ease the chest pain associated with pericarditis. Once the doctors gave a name to my symptoms and I was able to read about it, I exclaimed, “HA! I’m not crazy!” Well, maybe I am, but not about this!
When you see your doctor for chest pain, tests will be done. Lots of tests. Doctors don’t like their patients dying, so take complaints of chest pain quite seriously. Even if you insist that it’s not your heart, it’s your lungs, they will ignore you and focus on your heart. Expect to have an electrocardiogram (ECG/EKG) done almost immediately. This not only tells the doctor what your heart is doing at that moment, but can show evidence of a past heart attack.1
Stethoscopes are a great invention. In the case of pericarditis, the layers of the pericardium can rub against one another, and doctors are often able to hear this rubbing. It’s fascinating. Painful, but fascinating.
Another test, but one that can’t be done in a lot of primary care offices, is an echocardiogram (echo). This is an ultrasound of the heart, and in addition to an ECG is one of the tests that can be used in diagnosing pericarditis. Positive results are considered conclusive, however negative results are not.
A chest x-ray can show what’s going on with your lungs, and will also show if the heart is enlarged.
MRI can be done to check the thickness of the pericardium, but is not likely to be one of the tests ordered initially.
Labs might also be ordered. This is especially true if you go to the ER from your doctor’s office. They’ll completely ignore your pcp’s input and order a plethora of tests to measure inflammation and make sure you’re not having a heart attack.2
- Acute pericarditis appears suddenly and lasts fewer than three weeks.
- Incessant pericarditis is continuous and usually lasts 4-6 weeks, but definitely less than 3 months.
- Recurrent pericarditis is when symptoms of acute pericarditis resolve completely, the patient is symptom-free, and then 4-6 weeks later the symptoms occur again.
- Chronic pericarditis lasts longer than 3 months.
The Art of Medicine
Eventually I saw a cardiologist. He’s a fantastic guy. He read the history my family doctor sent, listened to my story, did an exam, and read the ECG. Tired of waiting for the ultra-slow wifi to work, he said, “Let’s do this the old fashioned way,” and retrieved a couple tomes from his office – including one that he said used to be the Bible of cardiology. It was kinda neat to watch him look things up just to confirm he was remembering things accurately, and he showed me in his books what it says about RA and pericarditis. Then he told me that he’d check up-to-date once he had a better internet connection.
After that, he showed me my ECG and explained that the machine was reading it as normal, but that’s not how he read it. And he carefully showed me the exact places on all those wiggly lines that he thinks look like my readings are abnormal, as if I were able to read ECG’s. I can’t, but he made it sound fascinating, didn’t treat me like an idiot, and I’m tempted to get a book to see if I can pick up the basics of reading ECG’s.
Medicine isn’t just feeding data into a computer that turns around and spits out a diagnosis and treatment plan. There’s an art to listening to patients, asking the right questions to get all the assorted symptoms that the patient didn’t even think to mention, and putting everything together. Then after determining a diagnosis, doctors still need to figure out a treatment plan. Every patient is different.
Since this is inflammation, it makes sense that anti-inflammatories would be the first line of treatment. But RA patients already know to take ibuprofen before bothering their doctors with a little inflammation, which means my cardiologist jumped directly to the next step.
Colchicine is a gout medicine that works to reduce inflammation, and is one of the most common pericarditis treatments. My insurance has this as a Tier II med, so be forewarned. The most common side effect is needing frequent trips to the bathroom with lots of TP and air freshener, but if you’re already taking something like sulfasalazine, that is unlikely to be a problem 🙂
Steroids can also be prescribed to reduce the inflammation. It’s nice to know there are options if the colchicine doesn’t work. Frankly, given the cost difference, my personal preference would be to deal with prednisone, but there’s the usual love/hate issue when that medicine is prescribed.
Here’s hoping your life is less eventful!
1 If the ECG’s automated results say “inferior infarct, age undetermined” do not panic. It might mean that you had a small heart attack at some time in the past, but it also might mean that the machine isn’t particularly reliable and your results should be interpreted by a skilled cardiologist who will say, “don’t worry; you’re fine.” If the doctor says, “Don’t worry; the machine doesn’t know what it’s talking about,” believe the doctor.
2 If you go to the ER from your doctor’s office, they’ll repeat the ECG and also draw blood to run every test possible in an effort to discover whether or not you’re having a heart attack. When they announce that you’re not having a heart attack, feel free to respond, “Nobody ever thought I was having a heart attack. I am here because my doctor told me to come here for an echocardiogram because none of the cardiologists can see me sooner than two weeks.” Better yet, it might be appropriate to be proactive at the very beginning of the visit and insist that they enter “sent by pcp for an echo” as your chief complaint, or they’ll get it all wrong and think that you’re there for chest pain. To tell the truth, the ER is a horrible experience and if I’m ever sent again, I will take with me the name of the ER doctor with whom my pcp spoke. And if it’s the height of flu season, beg to be sent anywhere else.