2015 ESC Guidelines for Pericardial Disease
- Adler Y, Charron P, Imazio M, et al.
- 2015 ESC Guidelines for the Diagnosis and Management of Pericardial Diseases. Eur Heart J 2015;Aug 29:[Epub ahead of print].
This is a 2015 update from the European Society of Cardiology (ESC) on the management of pericardial disease. The following are key points to remember:
- Acute pericarditis (diagnosis). The diagnosis of acute pericarditis can be made with at least two of the following four criteria: pericarditic chest pain, pericardial rub, new widespread ST-segment elevation or PR depression, and new or worsening pericardial effusion. Supporting findings can include elevation of inflammatory markers (C-reactive protein, erythrocyte sedimentation rate, white blood cell count), and evidence of pericardial inflammation on imaging (computed tomography [CT], cardiac magnetic resonance [CMR]).
- Acute pericarditis (prognosis). Major predictors of poor prognosis in acute pericarditis are fever >38°C, subacute onset, large pericardial effusion, cardiac tamponade, and lack of response to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) after ≥1 week of therapy; minor predictors are myopericarditis, immunosuppression, trauma, and oral anticoagulation therapy. Outpatient management is recommended for low-risk patients (no risk factors), and inpatient management is recommended for patients with ≥1 risk factor.
- Acute pericarditis (treatment). Aspirin (750-1000 mg every 8 hours for 1-2 weeks) or NSAIDs (ibuprofen 600 mg every 8 hours for 1-2 weeks) with gastric protection are recommended as first-line therapy for acute pericarditis. Colchicine (0.5 mg daily [<70 kg] or BID [≥70 kg] for 3 months) is recommended as first-line therapy as an adjunct to aspirin/NSAID therapy.
- Incessant, recurrent, and chronic pericarditis. Incessant pericarditis lasts for >4-6 weeks, but <3 months without remission. Recurrent pericarditis is pericarditis that recurs after a symptom-free interval of at least 4-6 weeks. Chronic pericarditis is pericarditis lasting >3 months. Aspirin or NSAIDs until symptom relief plus colchicine (for 6 months) is recommended for recurrent pericarditis.
- Cardiac tamponade. Common causes of cardiac tamponade include pericarditis, tuberculosis, iatrogenic (invasive procedure-related, post-cardiac surgery), trauma, and neoplasm/malignancy. Uncommon causes include collagen vascular diseases (systemic lupus erythematosus, rheumatoid arthritis, scleroderma), radiation, post-myocardial infarction, uremia, aortic dissection, bacterial infection, and pneumopericardium.
- Constrictive pericarditis. Constrictive pericarditis can occur after virtually any pericardial disease, but only rarely follows acute pericarditis. Pericardiectomy is the mainstay of treatment for chronic permanent constriction. Medical therapy for specific conditions (e.g., tuberculous pericarditis) is recommended to prevent the progression of constriction.
- Multimodality imaging. Imaging for pericardial disease can include chest x-ray, echocardiography, CT, CMR, positron emission tomography (PET) or PET/CT, and cardiac catheterization.
- Specific pericardial syndromes. Recommendations are provided for specific pericardial conditions, including viral pericarditis, bacterial pericarditis, pericarditis in renal failure, pericardial involvement in systemic autoimmune and auto-inflammatory diseases, post-cardiac injury syndromes, traumatic pericardial effusion and hemopericardium, pericardial involvement by neoplastic disease, and other forms of pericardial involvement including radiation pericarditis.
- Interventional techniques and surgery. Pericardiocentesis, guided by fluoroscopy or echocardiography, is the gold standards for pericardial drainage and biopsy. Pericardioscopy permits visualization of the pericardial sac, and allows targeted biopsy. Surgical intervention for pericardial diseases includes pericardial window (to allow pericardial fluid [usually malignant] to drain to the pleural space and prevent tamponade), and pericardiectomy (for constrictive pericarditis).
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