adjunctive therapy

[Patricia__0__0]

Posted by Patricia on July 21, 1999 at 09:09:52
I have had chest pain and throbbing in my left arm and shoulder for sixteen months and counting.  In October of 1998 I had a portion of the pericardium removed and between 200-300ccs of fluid removed.  The fluid showed nothing of origin for the cause and I was told it was probably viral.  
My question is: in addition to medicine(I take Indocin three times a day which helps me function) is there anything else that's been found to help the problem? Exercises, alternative medicine, etc.?  I try to walk 2-3 times a day for short distances(less than a mile) and eat a low fat diet.    

Posted by CCF CARDIO MD - CRC on July 21, 1999 at 09:57:42
Dear Patricia,
It sounds like what you are describing is viral pericarditis.  Acute pericarditis classically presents with progressive, often severe, chest pain over hours. This mechanical pain is typically postural, being worse on lying supine and relieved by sitting forward. It is often pleuritic and aggravated by coughing and swallowing. The pain may radiate to the neck, and less frequently to the arms and back, making differentiation from coronary ischemic pain more difficult. There is often a low-grade fever associated with viral and idiopathic pericarditis, while purulent pericarditis is associated with very high fevers and systemic sepsis.
The presence of a pericardial rub is pathognomonic for pericarditis, though its absence does not exclude the syndrome. This "to and fro" rasping sound has a timing consistent with the cardiac cycle. It is best appreciated with the diaphragm of the stethoscope applied to the lower left sternal edge and is creaking in nature-like leather on leather. The sound classically has a triple cadence, with components related to (a) atrial systole, (b) ventricular systole and (c) ventricular diastole. In one-third of cases, the rub is biphasic, while in 10% it is monophasic. The intensity of the sound can be attenuated by subcutaneous tissue thickness and hyperinflated lung volume. Further, the development of a pericardial effusion as part of the inflammatory syndrome can lead to waxing and waning of the rub over days, though a loud pericardial rub can still be heard occasionally in the presence of a significant effusion. The sound should be differentiated from a pleural rub, which, while similar in character, is timed with the respiratory cycle; subcutaneous emphysema, which may be an associate in post surgical or traumatic cases; and loud intracardiac murmurs such as ventricular septal defect.
Investigations
The electrocardiogram represents the most useful diagnostic test in acute pericarditis . Inflammation of the sub-epicardial myocardium is thought to be the mechanism producing ST- and T-wave changes, while inflammation of the atrium is thought to cause the PR-segment changes. In contrast to the regional ST changes of myocardial ischemia, pericarditis produces widespread ECG changes in limb and precordial leads. Four phases of ECG abnormalities have been recognized: Stage 1, with ST elevation and upright T waves, is present in 90% of cases. Over days the ST changes resolve and the ECG may look normal (Stage II). There may be further evolution to T-wave inversion (Stage III) and finally to normal (Stage IV).
The ECG abnormalities should be differentiated most importantly from acute myocardial ischemia. The ST changes are more widespread in pericarditis, lack Q-waves and have a typical "saddle-shaped" or concave appearance. The other important differential diagnosis of these ECG changes is the "early repolarization" pattern. While difficult without clinical correlation, differentiation can be made by the presence of PR segment elevation (especially aVR) and ST elevation in V6, which is uncommon in the early repolarization syndrome. Most patients with acute pericarditis remain in sinus rhythm.
Chest radiography contributes relatively little to the diagnosis of acute pericarditis. The presence of cardiomegaly may be seen in the minority of cases where a significant pericardial effusion has accumulated. Laboratory analysis of blood often shows a modest leukocytosis and raised sedimentation is rate. Radionuclide scanning with In-111385, Ga-67386,387 has been reported to be useful in identifying the pericardium as the source of an inflammatory syndrome of unknown diagnosis in some patients. MRI, with Gd-DTPA enhancement, has identified specific regions of the pericardium involved in the inflammatory process.
The following diagnostic algorithm has been proposed. All patients should have a complete history and physical examination, electrocardiography, and chest radiography. Diagnosis specific testing should include tuberculin skin testing, rheumatoid factor and antinuclear antibody, viral studies from pharyngeal, and fecal swabs. In more complex cases (i.e., symptoms and signs lasting longer than 1 week, clinical evidence of tamponade, or purulent pericarditis), echocardiography, sputum/gastric aspirate for tubercle bacillus examination, and blood cultures are indicated. Pericardiocentesis (either percutaneous or surgical) is indicated for clinical tamponade, evidence for purulent pericarditis, high suspicion of tumor, or illness lasting longer than 1 week.
Treatment is with non-steroidal antiinflammatory drugs such as Indocin.  I know of no holistic methods of treatment for pericarditis.
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.