Νόσοι του περικαρδίου. Γεώργιος Λάζαρος Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Γ.Ν. Αθηνών

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1 Νόσοι του περικαρδίου Γεώργιος Λάζαρος Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Γ.Ν. Αθηνών

2 I do not have any conflict of interests relevant to this presentation to declare.

3 Pericardial syndromes o Acute and recurrent pericarditis, isolated pericardial effusion, and constrictive pericarditis represent the main pericardial syndromes.

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5 44 pages

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7 What is new in the recent guidelines?

8 1.A new classification has been proposed. 2.Specific diagnostic criteria have been provided for acute

9 Epidemiologic data o The incidence of acute pericarditis was 27.7 cases per 100,000 population/year and in 2/3 of cases affect males.

10 Etiology: infectious and non-infectious causes

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12 Diagnostic criteria for acute pericarditis Acute pericarditis is diagnosed when at least 2 of the following criteria are present: o Typical chest pain o Pericardial friction rub o Suggestive ECG changes (typically widespread ST-segment elevation, PR depression o New or worsening pericardial effusion Elevation of CRP is a confirmatory finding and evidence of pericardial inflammation by an imaging technique (CT or CMR) are considered supporting findings

13 Diagnostic criteria for recurrent pericarditis The patient should fulfill the following criteria: A) a documented first attack of acute pericarditis B) recurrent chest pain compatible with pericarditis C) and one or more of the following signs: o Fever o Pericardial friction rub o Typical ECG changes (widespread ST-segment elevation and/or PR depression) o New or worsening or pericardial effusion o Elevation of white blood cells or markers of inflammation

14 Diagnostic work up

15 Which patient requires hospitalization? Major o o o o o Fever>38o C Subacute onset Large pericardial effusion (>2cm in diastole) Cardiac tamponade Lack of response to aspirin or NSAIDs after at least 1 week of therapy Minor o o o o Myopericarditis Immunodepression (in particular HIV infection) Trauma Oral anticoagulant therapy Little W et al. Circulation 2006;113: Lange RA et al. NEJM 2004;351: Imazio M et al. Circulation 2010;121:

16 Therapeutic regimens

17 Aspirin is the drug for choice for those patients already receiving it

18 *Steroids should be administered at a dose of mg kg/die in case of NSAIDS allergy, intolerance or failure, in advanced kidney disease and in pregnancy after the 20th week of gestation *

19 Pericarditis with myocarditis o The 2015 ESC guidelines on the management of pericardial diseases report for the first time a specific chapter on these common conditions for clinical practice. o Hospitalization is recommended for diagnosis and monitoring in patients with myocardial involvement and differential diagnosis, especially with acute coronary syndromes.

20 o Coronary angiography (according to clinical presentation and risk factor assessment) is recommended in order to rule out acute coronary syndromes. o CMR is recommended (Class IC) for the confirmation of myocardial involvement

21 o The management of myopericarditis should follow that of pericarditis and has an overall good prognosis. o In perimyocarditis empirical antiinflammatory therapies (i.e. aspirin or NSAIDs) are usually prescribed to control chest pain, while corticosteroids are prescribed as a second choice in cases of NSAIDs contraindication.

22 Exercise restriction o A minimal restriction of 3 months has been arbitrarily defined according to expert consensus for pericarditis and 6 months for myopericarditis. o Athletes are recommended to return to competitive sports only after symptoms have resolved and diagnostic tests (i.e. CRP, ECG, and echocardiogram) have been normalized.

23 Triage of patients with evidence of cardiac tamponade

24 Management of patients with pericardial effusion

25 Imaging modalities Klein A, et al. J Am Soc Echocardiogr 2013;26:

26 The contribution of new echocardiographic techniques Strain Imaging: Differences in longitudinal and circumferential deformation may be useful to distinguish CP from restrictive cardiomyopathy. Constrictive pericarditis Restrictive cardiomyopathy Circumferential strain - Torsion - Early diastolic untwisting - Global longitudinal strain - Early diastolic tissue velocities - Klein A, et al. J Am Soc Echocardiogr 2013;26:

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29 Cardiac catheterization is not routinely used for the diagnosis of pericardial disease, as current non-invasive techniques are usually able to solve the differential diagnosis of a patient with the suspicion of heart disease involving the pericardium.

30 Transient constriction Feng DaLi et al. Circulation 2011, 124:

31 o In the absence of evidence that pericardial constriction is permanent and chronic, patients with newly diagnosed constrictive pericarditis who are hemodynamically stable may be given a trial of conservative management (antiinflammatory therapy with NSAIDs and/or corticosteroids) for 2 to 3 months before pericardiectomy is recommended. Imazio M, et al. Circulation 2010;121;

32 Concerns 1. Unfortunately, there are only few RCTs and prospective studies and thus most recommendations have been based on Task Force consensus (LOE C). 135 recommendations Level of evidence A Level of evidence B Level of evidence C 6 (5%) 30* (22%) 99 (73%) *17 recommendations concern neoplastic pericarditis

33 2. Specific ethnic issues have to be studied and addressed since current recommendations have been essentially based on studies performed in Caucasian populations especially from Western Europe.

34 Conclusion Sir William Osler ( ) o Probably no serious disease is so frequently overlooked by the practitioner. o Postmortem experience shows how often pericarditis is not recognized or goes to resolution and adhesion without attracting notice. The new guidelines offer a valuable tool to put the complex puzzle of pericardial diseases together Osler, The Principles and Practice of Modern Medicine, 1892 John Hopkins Hospital

35 Thank you for your attention

36 Treatment of pericardial constriction How should be treated How should not be treated Presence of increasing JVP Very early constriction (occult and functional class I) Need for diuretic therapy Transitory constriction Evidence of hepatic insufficiency Severe advanced disease (NYHA IV which implies an operative mortality of 30-40%) Reduced exercise tolerance Hoit B. Circulation 2002;105: