ESR or CMR? Which One Better Predicts Response to Medical Therapy in Pericardial Constriction?
A relatively common syndrome, constrictive pericarditis often represents a diagnostic and a therapeutic challenge. Pericardiectomy, the definitive treatment for most patients with this condition, carries significant morbidity and not infrequently leads to incomplete resolution of symptoms. Several series of patients who present an intermediate syndrome of sub-acute pericarditis with signs and symptoms of pericardial constriction have been described over the past few years.1 Many of these had partial or complete response to antinflammatory therapy without requiring surgery. Patients with "transient" pericardial constriction may present evidence of active inflammation, including elevated serum biomarkers and imaging markers of inflammation, such as late gadolinium enhancement on cardiac magnetic resonance imaging (DE-CMR)2 and increased 18-fluorodeoxyglucose uptake on positron emission tomography (PET-FDG)studies.3
Feng and coworkers performed a retrospective review of 29 patients with confirmed pericardial constriction and had DE-CMR prior to receiving treatment with antinflammatory drugs.4 The intensity and thickness of pericardial enhancement in their series was the strongest predictor of response to medical therapy, defined as at least one level of improvement of NYHA class symptoms. ESR and CRP, both serum markers of inflammation were higher in patients who responded to drug therapy, and correlated well with DE-CMR findings. Since only those patients who were referred for CMR and were treated with drugs were included, we do not know the prevalence of abnormal DE-CMR in other patients with classic chronic constriction. This information is important if we are seeking to use DE-CMR as criteria to select patients for medical therapy. Furthermore, we cannot determine from Fang's preliminary study whether DE-CMR provides incremental utility over biomarkers alone, given the selection bias and the lack of treatment standardization. Of note, most patients in their study were treated with steroids, which have been more recently associated with increased risk of recurrence when given to patients with acute pericarditis. Conversely, a minority of patients received colchicine, considered today first-line therapy.
Is "transient" pericardial constriction a variant form of pericarditis, a variant form of constriction, an intermediate stage or a completely separate entity? Until we obtain more detailed histological data, we will not know the answer to this question, which should help to elucidate what are the most appropriate diagnostic and therapeutic strategies for patients with "transient constriction". Until then we will continue to rely on the insights from Feng's study.
- Haley JH, Tajik AJ, Danielson GK, Schaff HV, Mulvagh SL and Oh JK. Transient constrictive pericarditis: causes and natural history. Journal of the American College of Cardiology. 2004;43:271-5.
- Taylor AM, Dymarkowski S, Verbeken EK and Bogaert J. Detection of pericardial inflammation with late-enhancement cardiac Copyright © 2014 American College of Cardiology Foundation magnetic resonance imaging: initial results. European radiology. 2006;16:569-74.
- Salomaki SP, Hohenthal U, Kemppainen J, Pirila L and Saraste A. Visualization of pericarditis by fluorodeoxyglucose PET. European heart journal cardiovascular Imaging. 2014;15:291.
- Feng D, Glockner J, Kim K, Martinez M, Syed IS, Araoz P, Breen J, Espinosa RE, Sundt T, Schaff HV and Oh JK. Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy: a pilot study. Circulation. 2011;124:1830-7.
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