title: Pericardial syndromes: an update after the ESC guidelines 2004.
abstract: Despite a myriad of causes, pericardial diseases present in few clinical syndromes. Acute pericarditis should be differentiated from aortic dissection, myocardial infarction, pneumonia/pleuritis, pulmonary embolism, pneumothorax, costochondritis, gastroesophageal reflux/neoplasm, and herpes zoster. High-risk features indicating hospitalization are: fever >38 °C, subacute onset, large effusion/tamponade, failure of non-steroidal anti-inflammatory drugs (NSAIDs), previous immunosuppression, trauma, anticoagulation, neoplasm, and myopericarditis. Treatment comprises 10-14-days NSAID plus 3 months colchicine (2 × 0.5 mg; 1 × 0.5 mg in patients <70 kg). Corticosteroids are avoided, except for autoimmunity, as they facilitate the recurrences. Echo-guided pericardiocentesis (±fluoroscopy) is indicated for tamponade and effusions >2 cm. Smaller effusions are drained if neoplastic, purulent or tuberculous etiology is suspected. In recurrent pericarditis, repeated testing for autoimmune and thyroid disease is appropriate. Pericardioscopy and pericardial/epicardial biopsy may clarify the etiology. Familial clustering was recently associated with tumor necrosis factor receptor-associated periodic syndrome (TNFRSF1A gene mutation). Treatment includes 10-14 days NSAIDs with colchicine 0.5 mg bid for up to 6 months. In non-responders, low-dose steroids, intrapericardial steroids, azathioprine, and cyclophosphamide can be tried. Successful management with interleukin-1 receptor antagonist (anakinra) was recently reported. Pericardiectomy remains the last option in >2 years severely symptomatic patients. In constriction, expansion of the heart is impaired by the rigid, chronically inflamed/thickened pericardium (no thickening ~20 %). Chest radiography, echocardiography, computerized tomography, magnetic resonance imaging, hemodynamics, and endomyocardial biopsy indicate the diagnosis. Pericardiectomy is the only treatment for permanent constriction. Predictors of poor survival are prior radiation, renal dysfunction, high pulmonary artery pressures, poor left ventricular function, hyponatremia, age, and simultaneous HIV and tuberculous infection.
authors.affiliation: Department of Cardiology, Clinical Center of Serbia and Belgrade University School of Medicine, Koste Todorovića 8, 11000, Belgrade, Serbia. seferovic@med.bg.ac.rs
authors.forename: Petar M
authors.initials: PM
authors.lastname: Seferović
authors.forename: Arsen D
authors.initials: AD
authors.lastname: Ristić
authors.forename: Ružica
authors.initials: R
authors.lastname: Maksimović
authors.forename: Dejan S
authors.initials: DS
authors.lastname: Simeunović
authors.forename: Ivan
authors.initials: I
authors.lastname: Milinković
authors.forename: Jelena P
authors.initials: JP
authors.lastname: Seferović Mitrović
authors.forename: Vladimir
authors.initials: V
authors.lastname: Kanjuh
authors.forename: Sabine
authors.initials: S
authors.lastname: Pankuweit
authors.forename: Bernhard
authors.initials: B
authors.lastname: Maisch
mesh_terms: D000208:Acute Disease; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage*; D001706:Biopsy; D002305:Cardiac Tamponade / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D003078:Colchicine / Q000008:administration & dosage*; D003937:Diagnosis, Differential; D006801:Humans; D010490:Pericardial Effusion / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D010492:Pericardiectomy / Q000379:methods; D020519:Pericardiocentesis / Q000379:methods; D010493:Pericarditis / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy; D010496:Pericardium / Q000473:pathology*; D011379:Prognosis; D012008:Recurrence; D012307:Risk Factors; D013577:Syndrome; D050257:Tubulin Modulators
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D050257:Tubulin Modulators; D003078:Colchicine