Pericarditis and Cancer - American College of Cardiology (2022)

Pericarditis Etiology

Most pericarditis cases are self-limiting with a relatively benign clinical course.1 The etiologic diagnosis of pericarditis is often elusive, and around two-thirds of cases are considered idiopathic or attributed to viral infections.2,3 Other risk factors are recent cardiothoracic surgery, myocardial infarction, and bacterial infection (e.g., tuberculosis), as well as autoimmune disease and cancer.3,4 In unselected cohorts of pericarditis patients, approximately 5% of cases were attributable to underlying cancer.3,5,6 Among patients with pericardial effusion, malignancy is more prevalent, ranging between 12% and 23% of pericarditis cases.7-10

Cancer Occurrence in Pericarditis Patients

Given the increased occurrence of cancer in subgroups of patients with pericarditis, the differential diagnosis between cancer and other underlying conditions is essential. Diagnosis of cancer as the cause of pericarditis requires imaging (e.g., a computed tomography [CT] scan or cardiac magnetic resonance [CMR] imaging), cytology of pericardial fluid, and ultimately biopsies, confirming malignant infiltration within the pericardial tissue.

(Video) Constrictive Pericarditis

Primary malignant tumors of the heart (mesotheliomas, fibrosarcomas, and angiosarcomas) are rare, and most cases of cancer-related pericarditis are caused by metastatic tumors of remote origin.11 Lung cancer is the most common cancer type that may be complicated by pericarditis. Other cancers often identified in pericarditis patients are lymphoma, leukemia, and malignant melanoma, in addition to breast, ovary, prostate, colon, gastric, kidney, and bladder cancer.12-19

Plausible mechanisms linking cancer to development of pericarditis include direct infiltration by malignant cancer cells from proximate structures, pericardial hemorrhage, or spread of cancer cells through the bloodstream.20 Among patients with known cancer disease, pericardial effusion may arise from cancer treatment, most frequently radiation therapy. Chemotherapy also can increase the risk of opportunistic viral or bacterial infections. As well, pericarditis may occur as part of the paraneoplastic syndrome.21

Case reports and descriptive studies first identified the potential link between pericarditis and cancer.12-18 Recently the link was documented in a large population-based cohort study.19 The study was based on several Danish national medical databases, with data cross-linked at the patient level. The study included patients admitted to hospital with pericarditis over a 20-year period (1994–2013) with no previous cancer diagnoses. Follow-up for cancer started upon admission for pericarditis and continued for up to 20 years.

The risk of receiving a cancer diagnosis subsequent to the hospital admission for pericarditis was compared with expected cancer risk in a population with a similar gender and age distribution. Overall, pericarditis patients had a 50% higher occurrence of subsequent cancer diagnoses than the comparison group. Within the first 3 months, the risk was 12-fold higher than expected.

(Video) Multimodality Cardiovascular Imaging of Patients with Pericardial Disease

The study's results indicate that pericarditis may be the first clinical manifestation of a hidden cancer, most frequently lung cancer, lymphoma, leukemia, and unspecified metastatic cancer. Prostate, kidney, bladder, ovary, and colon cancers also were detected shortly after pericarditis diagnosis. As noted above, the risk of a cancer diagnosis was highest within the first 3 months after the pericarditis diagnosis, and most pronounced among patients with pericardial effusion (wet pericarditis). Importantly, however, an increased risk also was observed among patients with dry pericarditis. Furthermore, the study indicated that elevated cancer risk may be associated with heart failure, chronic obstructive pulmonary disease, alcohol-related diagnoses, and recent pneumonia or empyema—in addition to pericardial effusion.19

Diagnostic Work-Up for Cancer in Patients Presenting with Pericarditis

The European Society of Cardiology's 2015 guidelines for pericarditis recommend assessment of inflammatory markers, renal and liver function, creatinine kinase, and troponin in all cases of suspected pericarditis. Imaging may be indicated in high-risk patients according to clinical indicators (e.g., large pericardial effusion).1

Clinical examination alone, including auscultation, ECG, and echocardiography, does not discriminate between malignant and non-malignant causes of pericarditis. Specific tumor markers, CT scans or CMR imaging can reveal the presence of cancer.7,22

(Video) Heart and Bones: Understanding Your Secondary Health Risks After Cancer Treatment

Physicians treating pericarditis should be aware of the increased risk of cancer. In particular, patients with pericardial effusion or underlying conditions such as heart failure, chronic obstructive pulmonary disease, alcohol-related diagnoses, or recent pneumonia or empyema may need to be considered high-risk patients and referred for a work-up targeted at diagnosing or ruling out incident cancer.

Still, it is important to consider the pros and cons of an extended diagnostic work-up in patients presenting with pericarditis. The absolute cancer risk among these patients is low. Accordingly, the number of patients needed to examine to detect additional cancers is high. The clinical utility of extended screening should not outweigh the economic and patient-related costs, including radiation exposure and anxiety associated with the diagnostic work-up.

Prognosis of Pericarditis and Cancer

Overall, cancer patients with acute idiopathic or viral pericarditis have a good long-term prognosis.23 However, some characteristics are associated with a less favorable course. Factors identified as indicators of poor 6-12 month survival include fever above 38°C, subacute course, large pericardial effusion or cardiac tamponade, and lack of response within seven days to non-steroidal anti-inflammatory drugs (NSAIDs).3 In particular, purulent pericarditis and pericardial effusion have serious implications for cancer prognosis.4,24,25 In-hospital mortality is higher among patients with heart failure or severe infections such as pneumonia or sepsis.15

(Video) Heart Minute | Colchicine for Recurrent AF after Ablation

The cancer stage distribution among patients presenting with pericarditis is comparable to that in cancer patients without this condition. Among patients with lung cancer, complicating pericarditis is a prognostic factor for both short-term and long-term cancer survival. Among patients with bladder and breast cancer, pericarditis may have an impact on or be a clinical marker of reduced long-term survival.19

References

  1. Adler Y, Charron P, Imazio M, et al. 2015 ESC guidelines for the diagnosis and management of pericardial diseases: the task force for the diagnosis and management of pericardial diseases of the European Society of Cardiology (ESC) endorsed by: the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015;36:2921-64.
  2. Little WC, Freeman GL. Pericardial disease. Circulation 2006;113:1622-32.
  3. Imazio M, Cecchi E, Demichelis B, et al. Indicators of poor prognosis of acute pericarditis. Circulation 2007;115:2739-44.
  4. Imazio M, Gaita F. Diagnosis and treatment of pericarditis. Heart 2015;101:1159-68.
  5. Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol 1985;56:623-30.
  6. Zayas R, Anguita M, Torres F, et al. Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol 1995;75:378-82.
  7. Imazio M, Spodick DH, Brucato A, Trinchero R, Adler Y. Controversial issues in the management of pericardial diseases. Circulation 2010;121:916-28.
  8. Corey GR, Campbell PT, Van Trigt P, et al. Etiology of large pericardial effusions. Am J Med 1993;95:209-13.
  9. Levy PY, Corey R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine (Baltimore) 2003;82:385-91.
  10. Sagrista-Sauleda J, Merce J, Permanyer-Miralda G, Soler-Soler J. Clinical clues to the causes of large pericardial effusions. Am J Med 2000;109:95-101.
  11. Burazor I, Imazio M, Markel G, Adler Y. Malignant pericardial effusion. Cardiology 2013;124:224-32.
  12. Pawlak Cieslik A, Szturmowicz M, Fijalkowska A, et al. Diagnosis of malignant pericarditis: a single centre experience. Kardiol Pol 2012;70:1147-53.
  13. Vergani D, Massironi L, Lombardi F, Fiorentini C. Carcinoid heart disease from ovarian primary presenting with acute pericarditis and biventricular failure. Heart 1998;80:623-6.
  14. Kazmierczak E, Joks M, Straburzynska E, et al. Exudative pericarditis in a pregnant woman as the first sign of non-hodgkin's lymphoma. Kardiol Pol 2011;69:825-6.
  15. Kyto V, Sipila J, Rautava P. Clinical profile and influences on outcomes in patients hospitalized for acute pericarditis. Circulation 2014;130:1601-6.
  16. Imazio M, Demichelis B, Parrini I, et al. Relation of acute pericardial disease to malignancy. Am J Cardiol 2005;95:1393-4.
  17. Sakai Y, Minouchi K, Ohta H, Annen Y, Sugimoto T. Cardiac tamponade originating from primary gastric signet ring cell carcinoma. J Gastroenterol 1999;34:250-2.
  18. Huang JY, Jiang HP, Chen D, Tang HL. Primary gastric signet ring cell carcinoma presenting as cardiac tamponade. World J Gastrointest Oncol 2011;3:67-70.
  19. Sogaard KK, Farkas DK, Ehrenstein V, Bhaskaran K, Botker HE, Sorensen HT. Pericarditis as a marker of occult cancer and a prognostic factor for cancer mortality. Circulation 2017;136:996-1006.
  20. Quint LE. Thoracic complications and emergencies in oncologic patients. Cancer Imaging 2009;9:S75-82.
  21. Mainzer G, Zaidman I, Hatib I, Lorber A. Intrapericardial steroid treatment for recurrent pericardial effusion in a patient with acute lymphoblastic leukaemia. Hematol Oncol 2011;29:220-1.
  22. Maggiolini S, De Carlini CC, Ferri LA, et al. The role of early contrast-enhanced chest computed tomography in the aetiological diagnosis of patients presenting with cardiac tamponade or large pericardial effusion. Eur Heart J Cardiovasc Imaging 2016;17:421-8.
  23. Imazio M, Brucato A, Barbieri A, et al. Good prognosis for pericarditis with and without myocardial involvement: results from a multicenter, prospective cohort study. Circulation 2013;128:42-9.
  24. Kim SH, Kwak MH, Park S, et al. Clinical characteristics of malignant pericardial effusion associated with recurrence and survival. Cancer Res Treat 2010;42:210-6.
  25. Gornik HL, Gerhard-Herman M, Beckman JA. Abnormal cytology predicts poor prognosis in cancer patients with pericardial effusion. J Clin Oncol 2005;23:5211-6.

Keywords: Pericardial Effusion, Cardiac Tamponade, Hemangiosarcoma, Risk Factors, Urinary Bladder Neoplasms, Troponin, Ovary, Pericarditis, Mesothelioma, Melanoma, Lymphoma, Biopsy, Tomography, X-Ray Computed, Echocardiography, Breast Neoplasms, Tuberculosis, Lung Neoplasms, Pneumonia, Pulmonary Disease, Chronic Obstructive, Heart Failure, Empyema, Leukemia, Anti-Inflammatory Agents, Non-Steroidal, Autoimmune Diseases, Paraneoplastic Syndromes, Auscultation, Colonic Neoplasms, Fibrosarcoma, Electrocardiography, Myocardial Infarction, Magnetic Resonance Spectroscopy, Tomography, Cardiotoxicity

(Video) Cardiovascular Disease in Cancer Patients by Dr. A.B.M. Nizam Uddin sir


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FAQs

What type of cancer can cause pericarditis? ›

Lung cancer is the most common cancer type that may be complicated by pericarditis. Other cancers often identified in pericarditis patients are lymphoma, leukemia, and malignant melanoma, in addition to breast, ovary, prostate, colon, gastric, kidney, and bladder cancer.

Is pericarditis a symptom of cancer? ›

Among patients with acute pericarditis or pericardial effusions, cancers of the lung and breast and hematologic malignancies are diagnosed most frequently. Case reports describe pericarditis as an early manifestation of lymphoma, gastric cancer, or ovarian cancer.

Is Covid linked to pericarditis? ›

Pericarditis is a potential presentation of COVID-19. COVID-19 can have an atypical presentation with non-respiratory symptoms. Recognition of an atypical symptom of COVID-19 allows for early isolation and limits the spread.

Can chemo cause pericarditis? ›

Cancer treatment (chemotherapy and radiotherapy) may affect the pericardium leading to pericarditis and myopericarditis. Pericardial effusions, tamponade and constrictive pericarditis are complications that can also occur.

What cancers cause fluid around heart? ›

Lung cancer, breast cancer, melanoma, and lymphoma can cause fluid to build up around your heart. In some cases, the chemotherapy drugs doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan) can cause a pericardial effusion. This complication is rare .

Which symptom is common with the cancer complication of pericardial effusion? ›

If pericardial effusion signs and symptoms do occur, they might include: Shortness of breath or difficulty breathing (dyspnea) Discomfort when breathing while lying down. Chest pain, usually behind the breastbone or on the left side of the chest.

Why do cancer patients get pericardial effusions? ›

The extra fluid causes pressure on the heart, which keeps it from pumping blood normally. Lymph vessels may be blocked, which can cause infection. Malignant pericardial effusions are most often caused by lung cancer, breast cancer, melanoma, lymphoma, and leukemia.

Can you have cancer of the pericardium? ›

Experienced, Multidisciplinary Teamwork. Pericardial cancer is cancer that develops in the pericardium, the membrane that surrounds the heart, or cancer that has spread from another location (most commonly the lungs) to the pericardial sac. The first signs of this cancer are often shortness of breath and fatigue.

How long can you live with malignant pericardial effusion? ›

Survival rates are consistently poor in patients with malignancy who present with a pericardial effusion. In our series, patients had a median survival of 2.6 months. Patients with lung cancer had a median survival of 2.1 months while those with other types of cancer of 4.7 months.

Which viruses cause pericarditis? ›

Causative viruses include coxsackievirus B, echovirus, adenoviruses, influenza A and B viruses, enterovirus, mumps virus, Epstein-Barr virus, human immunodeficiency virus (HIV), herpes simplex virus (HSV) type 1, varicella-zoster virus (VZV), measles virus, parainfluenza virus (PIV) type 2, and respiratory syncytial ...

Does diet affect pericarditis? ›

Your provider may recommend a low-salt diet if you have constrictive pericarditis. Avoid saturated fats, alcohol, and sugars, which can increase inflammation and weaken your immune system.

Can pericarditis be caused by stress? ›

Stress cardiomyopathy (CMP) has been described as a complication of post-myocardial infarction pericarditis (Dressler syndrome). Stress CMP can also be complicated by pericarditis. We describe the novel observation where idiopathic pericarditis is the primary disease, which precipitated stress CMP.

Does laying down make pericarditis worse? ›

A common symptom of acute pericarditis is a sharp, stabbing chest pain, usually coming on quickly. It's often is in the middle or left side of the chest, and there may be pain in one or both shoulders. Sitting up and leaning forward tends to ease the pain, while lying down and breathing deep worsens it.

How is malignant pericardial effusion treated? ›

In many cases, drainage for several days with an indwelling catheter alleviates the effusion without subsequent recurrence. Systemic antitumor therapy with chemotherapy or radiation therapy is effective in controlling malignant effusions in cases of sensitive tumors such as lymphomas, leukemias, and breast cancer.

What drugs can cause pericardial effusion? ›

Causes of Pericardial Effusion

Certain prescription drugs, such as hydralazine, a medication for high blood pressure; isoniazid, a tuberculosis drug; and phenytoin, a medication for epileptic seizures. Chemotherapy drugs, such as doxorubicin and cyclophosphamide.

What can make pericarditis worse? ›

Get worse when coughing, lying down or taking a deep breath. Get better when sitting up or leaning forward.

Is pericardial effusion always malignant? ›

Pericardial Effusions With Cancer

Pericardial effusions may occur with any type of cancer, but the most common include lung cancer, breast cancer, and lymphomas. With lung cancer, pericardial effusions are very common, with many people undergoing radiation therapy for lung cancer developing some degree of an effusion.

Can fluid around the heart be cancerous? ›

Pericardial effusion is extra fluid around the heart. Pericardial effusion may be caused by cancer or other conditions. Signs and symptoms of pericardial effusion include dyspnea (shortness of breath) and cough. Pericardial effusion usually occurs in advanced cancer.

Can malignant pericardial effusion be cured? ›

Systemic antitumor therapy with chemotherapy or radiation therapy is effective in controlling malignant effusions in cases of sensitive tumors such as lymphomas, leukemias, and breast cancer. Local sclerotherapy with tetracycline hydrochloride or bleomycin sulfate is also effective and associated with low morbidity.

What is the most common cause of pericardial effusion? ›

Lung cancer is the most common cause of the malignant pericardial effusion. Trauma: Blunt, penetrating, and iatrogenic injury to the myocardium, aorta, or coronary vessels can lead to the accumulation of blood within the pericardial sac.

Is pericarditis serious? ›

Pericarditis causes chest pain and a high temperature. It's not usually serious, but it can cause serious health problems. Get medical advice if you have chest pain.

Can pericarditis be misdiagnosed? ›

Pericarditis can mimic other conditions, especially myocardial infarction. Family physicians should be alert to the possibility of pericarditis in patients with chest pain, because misdiagnosis can have potentially fatal consequences.

Can leukemia cause pericarditis? ›

Acute myeloid leukemia (AML) is frequently associated with pericardial effusion but infrequently presents with cardiac tamponade or effusive constrictive pericarditis. This case report highlights a presentation of cardiac tamponade identified with transthoracic echocardiography (TTE).

What is pericardial cancer? ›

Experienced, Multidisciplinary Teamwork. Pericardial cancer is cancer that develops in the pericardium, the membrane that surrounds the heart, or cancer that has spread from another location (most commonly the lungs) to the pericardial sac. The first signs of this cancer are often shortness of breath and fatigue.

Why does cancer cause fluid around the heart? ›

The tumor causes extra fluid to build up in the space between the thin layer of tissue covering the lung and the thin layer of tissue covering the chest wall (pleural effusion), between the sac that covers the heart and the heart (pericardial effusion), or in the abdominal cavity (ascites).

Does lung cancer cause pericardial effusion? ›

Lung cancer is the most common cause of pericardial involvement and studies have shown a prevalence of about 33% to 50% among all malignant pericardial effusions. Breast cancer, with a known prevalence of 18% per Strobbe et al., is the second most common cause of malignant pericardial effusion [3].

These are cardiac tamponade (compression of the heart caused by extra fluid in the pericardium), chronic pericarditis (long-term inflammation of the pericardium), or constrictive pericarditis (thickening and scarring of the pericardium).. Tamponade occurs when fluid accumulating in the pericardial sac (a condition called pericardial effusion ) prevents the heart from filling completely.. Constrictive pericarditis occurs when a chronically inflamed pericardial sac stiffens and loses its elasticity, which (similar to tamponade) prevents the heart from filling completely.. If pericardial effusions continue to recur, surgery can be done to create a permanent opening (a so-called pericardial window), that allows the fluid to drain from the pericardial sac, thus preventing tamponade.. Additional Reading Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines For The Diagnosis And Management Of Pericardial Diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS).

The chest pain from pericarditis may feel like pain from a heart attack .. Chronic effusive pericarditis and chronic constrictive pericarditis.. Two serious complications of pericarditis are cardiac tamponade (tam-po-NAD) and chronic constrictive pericarditis.. In pericarditis, the layers of tissue become inflamed and can rub against the heart, causing chest pain.. Two serious complications of pericarditis are cardiac tamponade and chronic constrictive pericarditis.

Regarding clinical management and therapy of acute pericarditis, it is not mandatory to search for the aetiology in all patients, especially in countries with a low prevalence of tuberculosis (TB) because of the relatively benign course associated with the common causes of pericarditis and the relatively low yield of diagnostic investigations [1].. Cardiac tamponade rarely occurs in patients with acute idiopathic pericarditis, and is more common in patients with a specific underlying aetiology, such as malignancy, TB or purulent pericarditis.. Approximately 15-30% of patients with idiopathic acute pericarditis who are not treated with colchicine will develop either recurrent or incessant disease, while colchicine may halve the recurrence rate.. Colchicine is recommended as first-line therapy for acute pericarditis as an adjunct to aspirin/NSAID therapy.. Recurrent pericarditis is diagnosed with a documented first episode of acute pericarditis, a symptom-free interval of four to six weeks or longer and evidence of subsequent recurrence of pericarditis.. Medical therapy of pericardial diseases: part II: noninfectious pericarditis, pericardial effusion and constrictive pericarditis .. Imazio M., Bobbio M., Cecchi E., Demarie D., Demichelis B., Pomari F., Moratti M., Gaschino G., Giammaria M., Ghisio A., Belli R., & Trinchero R. Colchicine in addition to conventional therapy for acute pericarditis: results of the COLchicine for acute PEricarditis (COPE) trial.

Videos

1. CMR in Cardio-Oncology, Dr. Juan Lopez-Mattei
(MonteHeart Lectures)
2. JACC: CardioOncology Video Case Presentation | Early Immune Checkpoint Inhibitor Cardiotoxicity
(American College of Cardiology)
3. Multimodality Imaging Guided Therapy; New Therapeutics in Pericarditis, Dr. Allan Klein
(MonteHeart Lectures)
4. Cardiotoxicity from Immunotherapy: Can Advanced Cardiac Imaging Meet the Challenge?
(Yale Cardiovascular Medicine Grand Rounds)
5. Cardio _oncology,board Review
(Cardiology Review)
6. Heart Failure A.S.I.A. Webinar
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