Hemorrhagic pericarditis is inflammation of the thin sac around the heart when the fluid inside it contains blood. The sac is called the pericardium, and it normally holds a small amount of fluid to help the heart move smoothly. This type of inflammation may occur with cancer, tuberculosis, or after heart surgery. The blood and extra fluid can sometimes press on the heart and affect its pumping.
What Makes Hemorrhagic Pericarditis Different From Other Types?
The pericardium is a protective, two-layered sac that surrounds the heart. Normally, a small amount of fluid between these layers reduces friction as the heart beats. Pericarditis develops when the sac becomes inflamed. In hemorrhagic pericarditis, the inflammatory fluid contains blood mixed with other material, such as fibrin or inflammatory cells. This distinguishes it from forms of pericarditis in which the fluid is mainly clear or contains other substances.
Hemorrhagic pericarditis is a description of the type of inflammation and fluid present, rather than a single disease with one cause. The amount of blood and fluid can vary, and the condition may develop alongside an underlying infection, cancer, or injury. According to the MSD Manual Professional Edition, pericardial fluid can range from clear fluid to blood, pus, or fluid containing both blood and other components.
Hemorrhagic pericarditis is also different from hemopericardium. Hemopericardium means blood has accumulated inside the pericardial sac. It can occur because of bleeding after an injury or cardiac procedure, a tear in the heart wall, or an aortic dissection. Blood in the sac can cause inflammation, but the two terms do not describe exactly the same process.
What Causes Hemorrhagic Pericarditis?
Several conditions can cause blood to enter the pericardial space while the surrounding tissue becomes inflamed. Identifying the underlying cause is important because treatment differs depending on whether the problem involves infection, cancer, a recent procedure, or active bleeding.
- Cancer: Cancers that spread to the pericardium, including lung cancer, breast cancer, and certain blood cancers, can cause a bloody pericardial effusion.
- Tuberculosis: This bacterial infection can affect the pericardium and cause inflammation with blood in the fluid, particularly in regions where tuberculosis is common.
- Heart surgery or procedures: Bleeding or inflammation may occur after surgery involving the heart or following certain cardiac procedures.
- Other infections: Some bacterial infections can cause substantial inflammation of the pericardium and may produce bloody fluid.
- Bleeding disorders or medicines: Conditions that impair normal blood clotting, including the effects of some blood-thinning medicines, may contribute to bleeding into the pericardial space.
- Chest injury or damage to the heart or major blood vessels: Trauma, a tear in the heart wall, or an aortic dissection can cause blood to collect around the heart, sometimes with associated pericardial inflammation.
The National Library of Medicine's StatPearls review of pericarditis identifies malignancy, tuberculosis, and complications following cardiac surgery as important associations of hemorrhagic pericarditis. The underlying cause is not always immediately apparent, so the medical evaluation may include tests for infection, cancer, and other relevant conditions.
What Symptoms Can Occur?
The symptoms depend on the degree of inflammation, how much fluid collects around the heart, and how quickly it accumulates. Some people mainly experience symptoms of pericardial inflammation, while others develop signs that the fluid is interfering with the heart's ability to fill and pump blood.
- Chest pain: Pain may feel sharp or aching, become worse with deep breathing or lying flat, and improve when sitting up and leaning forward.
- Shortness of breath: Fluid around the heart can contribute to breathing discomfort, particularly when lying down.
- Fever: A fever may occur when infection or active inflammation is present.
- Fast or noticeable heartbeat: The heart may beat faster or feel as though it is pounding or fluttering.
- Fatigue or weakness: These symptoms may accompany inflammation or an underlying illness.
- Lightheadedness or fainting: These can occur when the heart cannot pump enough blood to meet the body's needs.
Not everyone experiences all these symptoms. Some people with a slowly developing pericardial effusion have few noticeable symptoms until the fluid becomes substantial. The Mayo Clinic's information on pericardial effusion explains that fluid around the heart can cause chest discomfort, breathing difficulties, and lightheadedness, and that rapid accumulation can interfere with heart function.
When Is Hemorrhagic Pericarditis an Emergency?
The most important immediate complication is cardiac tamponade. This occurs when fluid or blood builds up in the pericardial sac and creates enough pressure to restrict the heart's filling. As a result, the heart cannot pump blood effectively, and blood pressure may fall. When blood collects rapidly, tamponade can develop even before a very large volume has accumulated.
Possible warning signs include severe or worsening breathlessness, chest pain, a rapid heartbeat, marked lightheadedness, fainting, or collapse. These symptoms do not establish a diagnosis on their own, but they may indicate a serious heart or circulation problem.
Seek emergency medical care immediately for new or persistent chest pain, severe breathing difficulty, unexplained fainting, or sudden deterioration. Do not wait for symptoms to resolve or attempt to assess the amount of fluid at home. The Mayo Clinic's guidance on pericardial effusion recommends emergency assessment for chest pain lasting more than a few minutes, difficult or painful breathing, or unexplained fainting.
How Is Hemorrhagic Pericarditis Diagnosed?
Diagnosis involves confirming inflammation or fluid around the heart, determining whether blood is present, checking whether heart function is affected, and investigating the underlying cause. Healthcare professionals consider symptoms, medical history, recent surgery or injury, current medicines, physical examination findings, and test results together.
Medical examination and heart tests
A clinician may listen for a pericardial friction rub, an unusual sound produced when inflamed layers of the pericardium move against each other. Blood pressure, heart rate, breathing, and other signs of circulation are also assessed. An electrocardiogram (ECG or EKG) records the heart's electrical activity and may reveal changes associated with pericarditis.
An echocardiogram, which uses ultrasound to create images of the heart, is especially useful. It can show fluid around the heart and help determine whether the fluid is affecting the heart's ability to fill. Additional imaging, such as a chest X-ray, computed tomography (CT) scan, or cardiac magnetic resonance imaging (MRI), may be used when more information is needed.
The American Heart Association's guidance on pericarditis symptoms and diagnosis describes the role of medical history, examination, ECG, echocardiography, blood tests, and other imaging in evaluating pericardial inflammation and related complications.
How is the cause of the bleeding identified?
Blood tests may look for inflammation, infection, abnormal blood counts, or problems with blood clotting. Further tests may be selected when tuberculosis, another infection, cancer, or a recent heart injury is suspected. A clinician may also review anticoagulant use and the timing of any recent cardiac surgery or procedure.
When fluid needs to be removed, a procedure called pericardiocentesis may be performed. A clinician uses imaging guidance to insert a needle and catheter into the pericardial space and drain fluid. The sample can be examined for evidence of infection, malignant cells, and other abnormalities. In some cases, surgical drainage or tissue sampling is needed to establish the cause or manage ongoing bleeding.
How Is Hemorrhagic Pericarditis Treated?
Treatment depends on the underlying cause, the quantity and rate of fluid accumulation, and whether the heart's function is affected. Management may require hospital care, particularly when there is significant bleeding or concern about cardiac tamponade. The immediate priority is to protect circulation and relieve pressure on the heart when necessary.
Draining blood or excess fluid
If fluid is placing significant pressure on the heart, urgent drainage may be needed. Pericardiocentesis can remove fluid through a catheter. When bleeding continues, blood has clotted, drainage is inadequate, or the source of bleeding needs to be repaired, surgery may be required. The procedure chosen depends on the clinical findings and the underlying cause.
Treating the underlying condition
Additional treatment is directed at the cause. Confirmed bacterial or tuberculous infection requires appropriate antimicrobial treatment. When cancer is responsible, treatment may involve cancer-directed therapy and measures to control recurrent fluid accumulation. If bleeding is related to a cardiac injury, vascular problem, bleeding disorder, or medicine, the relevant cause must be addressed.
Anti-inflammatory medicines may be appropriate for selected cases of pericarditis, but they are not a substitute for controlling active bleeding or relieving cardiac tamponade. Medication choices need to account for the cause of the condition and the person's bleeding risk. Medicines that affect blood clotting should not be stopped or changed without medical guidance unless emergency clinicians direct otherwise.
The Mayo Clinic's diagnosis and treatment guidance for pericardial effusion describes drainage procedures and surgery as options when fluid accumulation causes significant symptoms, threatens heart function, or requires correction of bleeding or another underlying problem.
What Affects Recovery?
Recovery varies according to the cause of the hemorrhagic pericarditis, how quickly the blood or fluid accumulated, whether cardiac tamponade developed, and how effectively the underlying problem can be treated. Prompt treatment can be particularly important when the heart's ability to fill is impaired. Some people recover after the underlying cause is treated and the fluid resolves, while others require continued monitoring or additional procedures if fluid returns.
Follow-up may include repeat echocardiograms, clinical examinations, and tests directed at the original cause. The care team will determine the appropriate monitoring schedule and whether further treatment is necessary. New or recurrent chest pain, breathlessness, fainting, or other concerning symptoms should be assessed promptly.