Myopericarditis versus viral or idiopathic acute pericarditis

The Myth of Colchicine in Treating Myopericarditis: Case Report and Literature Review

Myopericarditis is inflammation of the pericardium with concurrent myocardial involvement. The clinical presentation of myopericarditis is often with varying degrees of cardiac symptomatology. Its etiology is often idiopathic, but it may also be related to infectious and inflammatory prodrome. Symptoms are proportional to the extent and pattern of myocardial involvement. Many are diagnosed sub-clinically during the management of other systemic illnesses. Echocardiography and cardiac magnetic resonance imaging are important tools in the evaluation of myopericarditis, as the diagnosis of left ventricular dysfunction greatly affects the management, follow-up, and prognosis of these patients. The acute management of myopericarditis remains without clear direction and focuses on symptom control. The use of NSAIDs is often cautioned, as it has been described to actually accelerate the myocarditic process in animal models, possibly increasing mortality. Colchicine, a well-established anti-inflammatory agent, may have a role in the management of acute myopericarditis. We present two cases, each involving a young male, without underlying medical conditions, who presented to the emergency room with acute onset chest pain. Both were found to have elevated cardiac biomarkers and electrocardiographic (EKG) changes, admitted as in-patients and eventually diagnosed with acute myopericarditis. They made full recoveries and were eventually discharged home. Both were started on colchicine during hospitalization, which were continued for several months upon discharge. Overall, there is limited published data regarding the medical management of myopericarditis. There need to be prospective studies and registries to further our knowledge in the management of this illness.

Salmonella typhimurium myopericarditis: A case report and review of literature

BACKGROUND

Non-typhoidal salmonella (NTS) is a rare, but well-established cause of myopericarditis. Presenting symptoms may be varied, however often revolve around the dual presentation of both myopericarditis and infectious diarrhoea. Given the rarity of NTS related myopericarditis, we conducted a systematic review of the literature, identifying 41 previously reported cases.

CASE SUMMARY

We present the case of an otherwise healthy 39-year old male, presenting with chest pain in the setting of documented Salmonella typhimurium infection. After further investigation with echocardiogram and laboratory blood tests, a diagnosis of NTS associated myopericarditis was made, and the patient received antibiotic treatment with an excellent clinical outcome. Overall, myopericarditis is rare in NTS. Although treatment for myopericarditis has not been well established, there are guidelines for the treatment of NTS infection. In our review, we found that the majority of NTS cases has been pericarditis (27/42, 64.3%), with an average age of 48.3 years, and 71.4% being male. The average mortality across all cases was 31%.

CONCLUSION

Myopericarditis is a rare, but potentially serious complication of NTS infection, associated with an increased morbidity and mortality.

Predictors for In-hospital Mortality in Pediatric Patients with Acute Myocarditis – a Retrospective Study

Background: Acute myocarditis, a primary inflammatory cardiac disease commonly caused by viral infection, is an important cause of morbidity and mortality in children. Data obtained from forensic studies found an incidence of 15–33% for acute myocarditis in sudden deaths in the pediatric age group. Currently, there is a lack of data regarding the incidence and factors associated with short-term outcomes in pediatric patients admitted for acute myocarditis.

The aim of the study was to identify predictors for in-hospital mortality in a pediatric population admitted with acute myocarditis.

Material and methods: We conducted a retrospective observational cohort study that included 21 patients admitted for acute myocarditis. Clinical, laboratory, ECG, and imaging data acquired via 2D transthoracic echocardiography and cardiac magnetic resonance imaging were collected from the medical charts of each included patient. The primary end-point of the study was all-cause mortality occurring during hospitalization (period ranging from 10 to 14 days). The study population was divided into 2 groups according to the occurrence of the primary end-point.

Results: The mean age of the study population was 99.62 ± 77.25 months, and 61.90% (n = 13) of the patients were males. The in-hospital mortality rate was 23.9% (n = 5). Patients in the deceased group were significantly younger than the survivors (55.60 ± 56.18 months vs. 113.4 ± 78.50 months, p = 0.039). Patients that had deceased presented a significantly higher level of LDH (365 ± 21.38 U/L vs. 234.4 ± 63.30 U/L, p = 0.0002) and a significantly higher rate of ventricular extrasystolic dysrhythmias (60% vs. 6.25%, p = 0.02, OR: 22.5, 95% CI: 1.5–335) compared to survivors. The 2D echocardiography showed that patients that had deceased presented more frequently an impaired left ventricular ejection fraction (<30%) (p = 0.001) and a significantly higher rate of severe mitral regurgitation (p = 0.001) compared to survivors.

Conclusions: The most powerful predictors for in-hospital mortality in pediatric patients admitted for acute myocarditis were the presence of ventricular extrasystolic dysrhythmias on the 24h Holter ECG monitoring, impaired left ventricular systolic function (LVEF <30%), the presence of severe mitral regurgitation, and confirmed infection with Mycoplasma pneumoniae.

Meta-analysis for the value of colchicine for the therapy of pericarditis and of postpericardiotomy syndrome

BACKGROUND

Colchicine has been used as anti-inflammatory agent in pericardial effusion (PE). We sought to perform a meta-analysis of randomized trials assessing the efficacy and safety of colchicine in patients with pericarditis or postpericardiotomy syndrome (PPS).

METHODS

In the systematic literature search following the PRISMA statement, 10 prospective randomized controlled studies with 1981 patients with an average follow-up duration of 13.6 months were identified.

RESULTS

Colchicine reduced the recurrence rate of pericarditis in patients with acute and recurrent pericarditis and reduced the incidence of PPS (RR: 0.57, 95% CI: 0.44-0.74). Additionally, the rate of rehospitalizations as well as the symptom duration after 72 h was significantly decreased in pericarditis (RR 0.33; 95% CI 0.18-0.60; and RR 0.43; 95% CI 0.34-0.54; respectively), but not in PPS. Treatment with colchicine was associated with significantly higher adverse event (AE) rates (RR 1.42; 95% CI 1.05-1.92), with gastrointestinal intolerance being the leading AE. The reported number needed to treat (NNT) for the prevention of recurrent pericarditis ranged between 3 and 5. The reported NNT for PPS prevention was 10, and the number needed to harm (NNH) was 12, respectively. Late colchicine administration > 7 days after heart surgery did not reduce postoperative PE.

CONCLUSIONS

Our meta-analysis confirms that colchicine is efficacious and safe for prevention of recurrent pericarditis and PPS, while it reduces rehospitalizations and symptom duration in pericarditis. The clinical use of colchicine for the setting of PPS and postoperative PE after heart surgery should be investigated in further multicenter RCT.

Clinical significance of pleural effusions and association with outcome in patients hospitalized with a first episode of acute pericarditis

The clinical significance of pleural effusions (PLEs) in the setting of acute pericarditis remains poorly investigated. We sought to identify predictive factors for PLEs and their association with the short- and long-term prognosis of patients with acute pericarditis. We enrolled 177 patients hospitalized with a first episode of acute pericarditis. In all cases an extensive clinical, biochemical, and diagnostic work-up to detect PLEs and establish etiological diagnosis was performed. All patients included were prospectively followed for a maximum of 18 months (median 12, range 1-18) and complications were recorded. PLEs were detected in n = 94 cases (53.1% of the cohort; bilateral 53.2%, left-sided 28.7%, right-sided 18.1%) and were strongly associated with c-reactive protein (CRP) levels at admission (rho = 0.328, p < 0.001). In multivariate logistic regression, independent predictors for PLEs were female gender (OR = 2.46, 95% CI 1.03-5.83), age (per 1-year increment OR = 1.030, 95% CI 1.005-1.056), CRP levels (per 1 mg/L increment OR = 1.012, 95% CI 1.006-1.019) and size of pericardial effusion (per 1 cm increment, OR = 1.899, 95% CI 1.228-2.935). Bilateral PLEs were associated with increased risk for in-hospital cardiac tamponade (OR = 7.52, 95% CI 2.16-26.21). There was no association of PLEs with new onset atrial fibrillation or pericarditis recurrence during long-term follow-up (χ2 = 0.003, p = 0.958). We conclude that PLEs are common in patients hospitalized with a first episode of acute pericarditis. They are related to the intensity of inflammatory reaction, and they should not be considered necessarily as a marker of secondary etiology. Bilateral PLEs are associated with increased risk of in-hospital cardiac tamponade, but do not affect the long-term risk of pericarditis recurrence.

Clinical significance of myocardial involvement in acute idiopathic pericarditis

BACKGROUND

Acute idiopathic pericarditis (AIP) is frequently accompanied by myocardial involvement (AIPM). Although in acute myocarditis, the myocardial inflammation can lead to life-threatening complications, the outcome of patients with AIPM has been described as good. It remains unclear if a good prognosis of patients with AIPM reflects mild myocardial involvement or good medical management.

METHODS

A retrospective analysis of life-threatening complications and life-saving interventions in a cohort of 248 consecutive patients admitted to a single medical center between 2006 and 2017 with AIP (n = 169) or AIPM (n = 79). Major adverse cardiac events (MACE) included cardiac tamponade, cardiogenic shock, ventricular tachycardia, pericardiocentesis, pericardiectomy, large pericardial effusion and death.

RESULTS

Patients with AIPM were younger than patients with AIP (p < 0.001), and more often had left ventricular dysfunction (31.6% vs. 1.2%, p < 0.001) and less often had large pericardial effusion (1.3% vs. 13.6%, p = 0.002), and MACE (5.1% vs. 14.8%, p = 0.014). Cardiac tamponade occurred in 5.3% of the patients with AIP as opposed to 1.3% of the patients with AIPM (p = 0.176). Severe left ventricular dysfunction with cardiogenic shock occurred exclusively among patients with AIPM but the rate was low (2.5%). Life-saving interventions were used in both groups at comparable rates (2.5% vs. 5.3%, p = 0.510). There were no in-hospital deaths.

CONCLUSIONS

Myocardial involvement in acute pericarditis is associated with a low rate of severe left ventricular dysfunction and cardiogenic shock and a reduced rate of large pericardial effusion, resulting in a lower rate of MACE. Life-saving interventions were used at comparable rates in patients with and without myocardial involvement having excellent survival rates.

Pericarditis - Clinical presentation and characteristics of a pediatric population

INTRODUCTION

Pericarditis is an inflammation of the pericardium. It may be infectious or secondary to a systemic disease. The aim of this study was to analyze the clinical findings, course, treatment and follow-up of children diagnosed with pericarditis at our center.

METHODS

We performed a retrospective analysis of all children admitted to our pediatric cardiology unit with pericarditis between 2003 and 2015. Patient characteristics were summarized using frequencies and percentages for categorical variables and medians with percentiles for continuous variables.

RESULTS

Fifty patients were analyzed (40 male, 10 female) with a median age of 14 years. The most common diagnosis was acute pericarditis (80%). Thirty-five patients (70%) presented with chest pain and 26% reported fever. Cardiomegaly was identified on chest X-ray in 11 patients (22%), 30 patients (60%) had an abnormal ECG and 44 patients (80%) had alterations on the transthoracic echocardiogram. In 17 cases (34%) there was myocardial involvement. Forty-eight percent of patients presented with infectious pericarditis and the pathologic agent was identified in half of them. Postpericardiotomy syndrome was diagnosed in five cases. The first-line therapy was aspirin in 50% of cases. Pericardiocentesis was performed in 12 patients. The median length of stay was nine days. There was symptom recurrence in seven children.

CONCLUSIONS

In this study, acute infectious pericarditis was the most common presentation and about one third of patients also had myocarditis. The symptom recurrence rate was not negligible and is probably related to the type of therapy employed.

Acute pericarditis: a review of current diagnostic and management guidelines

This review examined the relevance of chest pain, pericardial friction rub, pericardial effusion and ECG changes in regard to the diagnosis of acute pericarditis. It also assessed the evidence for the management and therapeutic guidelines, specifically nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids. Overall, there appears to be a lack of research into pericarditis. The bulk of high-quality research seems to have been carried out prior to the publication of the European Society of Cardiology guidelines of 2015. Diagnostically, the current combination of symptoms, clinical signs and investigations offer reasonable criteria for diagnosis, but they are not a gold standard. Research into its therapeutic treatment options is required to address the effects of specific nonsteroidal anti-inflammatory drugs (NSAIDs).

Recurrent Pericarditis in Children and Adolescents

Recurrent pericarditis (RP) is a clinical syndrome characterized by recurrent attacks of acute pericardial inflammation. Prognosis quoad vitam is good, although morbidity might be significant, especially in children and adolescents. Multiple potential etiologies result in RP, in the vast majority of cases through autoimmune or autoinflammatory mechanisms. Idiopathic RP is one of the most frequent diagnoses, that requires the exclusion of all known etiologies. Therapeutic advances in the last decade have been significant with the recognition of the effectiveness of anti IL1 therapy, but a correct diagnostic and therapeutic algorithm is of key importance. Unfortunately, most of evidence comes from studies in adult patients. Here we review the etiopathogenesis, diagnosis and management of RP in pediatric patients.

Myopericarditis: recognition and impact in the military population

We present a case of a fit and well British Army officer with sudden-onset chest pain following a viral illness, on a background of arduous skiing over an 8-week period. This resulted in a 6-month downgrade with no clearly defined plan for return to full fitness and deployability. The diagnosis and differentiation of myopericarditis from other causes of chest pain is reviewed. The treatment and management of myopericarditis is summarised and commentary is made on the paucity of evidence underpinning the return to fitness guidelines. The impact of this condition primarily affecting young fit individuals, commonly exacerbated by viral illness and arduous activity, is discussed in the context of individual employability and operational capability in a military setting.

Alteplase Causing Cardiac Tamponade in the Setting of Recent Cardiac Pacemaker Placement

A 56-year-old female presented to the emergency department with evolving cardiac tamponade after receiving alteplase for acute ischemic stroke. This is the first case report of cardiac tamponade from thrombolytics in the setting of recent pacemaker placement. Point-of-care ultrasound was used to make the diagnosis quickly and expedite the patient to the operating room where a pericardial window was performed.

Acute and Recurrent Pericarditis

Acute and recurrent pericarditis is the most common pericardial syndrome encountered in clinical practice either as an isolated process or as part of a systemic disease. The diagnosis is based on clinical evaluation, electrocardiogram, and echocardiography. The empiric therapy is based on nonsteroidal anti-inflammatory drugs plus colchicine as first choice, resorting to corticosteroids for specific indications (eg, systemic inflammatory disease on corticosteroids, pregnancy, renal failure, concomitant oral anticoagulants), for contraindications or failure of the first-line therapy. The most common complication is recurrence, occurring in up to 30% of cases after a first episode of pericarditis.

Management of idiopathic recurrent pericarditis in adults and in children: a role for IL-1 receptor antagonism

Recurrent pericarditis is one of the most frequent pericardial diseases, affecting up to 30% of the patients who have experienced acute pericarditis. While the diagnosis of acute pericarditis is sometime straight forward, its etiology and therapeutic management are still a challenge for physicians. In developed countries, the idiopathic form is the most frequent, and the search for an infectious etiology is almost invariably negative. Nevertheless, since standard treatment with nonsteroidal anti-inflammatory drugs and colchicine is not always able to neutralize pericardial inflammation in recurrent pericarditis, anakinra, an IL-1 receptor antagonist, has been proposed as a possible therapeutic alternative for refractory forms. IL-1 is a cytokine that exerts a pivotal role in innate immunity and in the pathogenesis of some autoimmune diseases, such as rheumatoid arthritis, and in autoinflammatory disorders, as familial Mediterranean fever and cryopyrin-associated periodic syndromes. The successful management of patients with acute idiopathic recurrent pericarditis (IRP) needs a teamwork approach, where cardiologists, rheumatologists, clinical immunologists and internists are involved. In this review, we will discuss the clinical and therapeutical challenges of IRP both in adults and children from a clinical practice standpoint. We will also briefly illustrate the main pathogenic mechanisms of IRP to provide internists and cardiologists with the rationale for approaching the use of anakinra in selected clinical cases.

Recurrence of pericarditis after influenza vaccination: a case report and review of the literature

BACKGROUND

This case report describes a patient with pericarditis likely attributed to influenza vaccination (positive rechallenge), with a literature review.

CASE PRESENTATION

A 87-year old patient developed pericarditis after influenza vaccination, with acute chest pain, without ECG abnormalities or increased cardiac enzyme levels. Echocardiogram showed moderate pericardial effusion. Recovery was obtained through steroids One year later, few days after re-immunization, the patient experienced the same symptoms and was admitted to hospital with diagnosis of recurrence of pericarditis with severe pericardial effusion, again treated with steroids. Other possible causes were ruled out and the cardiologist recommended against influenza vaccinations in the future; the patient did not experience recurrence of pericarditis in the following 6 years. Cases of pericarditis following influenza immunization in the literature were also reviewed.

CONCLUSIONS

Pericarditis following immunization for influenza is very rarely reported in the literature. In a few cases, influenza vaccination seems likely responsible. We suggest considering recent immunization in patient's history as part of the differential diagnosis in elderly with chest pain.

Braun-Dullaeus R. Cardiogenic Causes of Fever

BACKGROUND

Persistent fever of unknown cause is only rarely of cardiac origin, but heart disease must be considered in the differential diagnosis. Aside from endocarditis, pericarditis and various other conditions may be responsible.

METHODS

This review is based on pertinent articles retrieved by a selective search in PubMed and Google Scholar employing the term "fever" in combination with "myocardial infarction," "pericarditis," "endocarditis," and "postcardiac injury," with additional consideration of current cardiological guidelines.

RESULTS

Endocarditis is associated with fever in 90% of cases, but 25-50% of patients also develop high body temperatures after acute myocardial infarction. In pericarditis, a temperature above 38°C indicates a poorer prognosis; if accompanied by other warning signs, it is an indication for hospitalization and pericardiocentesis. Fever can arise after cardiac surgical procedures as a manifestation of post - cardiotomy syndrome, a special type of perimyocarditis. There may be a latency period of up to 3 months.

CONCLUSION

Fever can have both infectious and non-infectious cardiac causes. Its interpretation depends on the clinical context. The evidence base for treatment is sparse, and controlled trials are needed.

Interleukin-1 blockade for the treatment of pericarditis

Pericarditis is a debilitating condition that results from profound inflammation of the pericardial tissue. Between 10 and 15% of first episodes of acute pericarditis will be followed by several episodes refractory to conventional treatment. Current standard of care for pericarditis treatment includes high-dose non-steroidal anti-inflammatory drugs, colchicine, and systemic corticosteroids, each associated with potentially severe toxicities and nominal efficacy. Interleukin-1 (IL-1), an apical pro-inflammatory cytokine, plays an important role as an autocrine magnifier of systemic inflammation in pericarditis. Interruption of the IL-1 circuit has been shown to have a favourable risk profile in several disease states. In this review, we discuss the growing body of evidence which supports the use of IL-1 blockade in the treatment of recurrent pericarditis as well as provide practical considerations for the use of IL-1 blockade in clinical practice.

ST Segment Elevation Is Not Always Myocardial Infarction: A Case of Focal Myopericarditis

Protocols exist on how to manage STEMI patients, with well-established timelines. There are times when patients present with chest pain, ST segment elevation, and biomarker elevation that are not due to coronary artery disease. These conditions usually present with normal coronary angiography. We present a case that was clinically indistinguishable from STEMI and that was diagnosed with focal myopericarditis on cardiac MRI.

Complicated Pericarditis: Understanding Risk Factors and Pathophysiology to Inform Imaging and Treatment

Most patients with acute pericarditis have a benign course and a good prognosis. However, a minority of patients develop complicated pericarditis, and the care of these patients is the focus of this review. Specifically, we address risk factors, multimodality imaging, pathophysiology, and novel treatments. The authors conclude that: 1) early high-dose corticosteroids, a lack of colchicine, and an elevated high-sensitivity C-reactive protein are associated with the development of complicated pericarditis; 2) in select cases, cardiovascular magnetic resonance imaging may aid in the assessment of pericardial inflammation and constriction; 3) given phenotypic similarities between recurrent idiopathic pericarditis and periodic fever syndromes, disorders of the inflammasome may contribute to relapsing attacks; and 4) therapies that target the inflammasome may lead to more durable remission and resolution. Finally, regarding future investigations, the authors discuss the potential of cardiovascular magnetic resonance to inform treatment duration and the need to compare steroid-sparing treatments to pericardiectomy.

Pericarditis as a Marker of Occult Cancer and a Prognostic Factor for Cancer Mortality

BACKGROUND

Pericarditis may be a serious complication of malignancy. Its significance as a first symptom of occult cancer and as a prognostic factor for cancer survival is unknown.

METHODS

Using Danish medical databases, we conducted a nationwide cohort study of all patients with a first-time diagnosis of pericarditis during 1994 to 2013. We excluded patients with previous cancer and followed up the remaining patients for subsequent cancer diagnosis until November 30, 2013. We calculated risks and standardized incidence ratios of cancer for patients with pericarditis compared with the general population. We assessed whether pericarditis predicts cancer survival by the Kaplan-Meier method and Cox regression using a matched comparison cohort of cancer patients without pericarditis.

RESULTS

Among 13 759 patients with acute pericarditis, 1550 subsequently were diagnosed with cancer during follow-up. The overall cancer standardized incidence ratio was 1.5 (95% confidence interval [CI], 1.4-1.5), driven predominantly by increased rates of lung, kidney, and bladder cancer, lymphoma, leukemia, and unspecified metastatic cancer. The <3-month cancer risk among patients with pericarditis was 2.7%, and the standardized incidence ratio was 12.4 (95% CI, 11.2-13.7). The 3- to <12-month standardized incidence ratio of cancer was 1.5 (95% CI, 1.2-1.7), subsequently decreasing to 1.1 (95% CI, 1.0-1.2). Three-month survival after the cancer diagnosis was 80% and 86% among those with and without pericarditis, respectively, and the hazard ratio was 1.5 (95% CI, 1.3-1.8). One-year survival was 65% and 70%, respectively, corresponding to a 3- to <12-month hazard ratio of 1.3 (95% CI, 1.1-1.5).

CONCLUSIONS

Pericarditis may be a marker of occult cancer and augurs increased mortality after a cancer diagnosis.

[Clinical characteristics and follow-up of patients with magnetic resonance imaging confirmed myopericarditis: A retrospective study]

INTRODUCTION

Pericarditis are frequently associated with some degree of concomitant myocardial involvement. Predominant pericarditis with limited myocardial involvement are named myopericarditis. Data regarding myopericarditis are scarce.

PATIENTS AND METHODS

Retrospective chart review of all patients admitted between 2002 and 2011 with magnetic resonance imaging confirmed myopericarditis.

RESULTS

Twenty-seven patients were included. Eighty-one percent were men, with median age of 32 years. Infectious disease preceded hospitalization in 55% of cases. Mean left ventricle ejection fraction at admission was 55% with focal myocardial impairment mainly localized in lateral and inferior walls. Coronary angiogram was performed in 37% of cases to rule out an ischaemic aetiology. We identified 5 cases (19%) of myopericarditis preceded by an episode of streptococcus group A throat infection. Non-sustained ventricular tachycardia was observed in 15% of cases. After a 2-year follow-up period, mortality rate was zero and recurrence rate was 15%.

CONCLUSIONS

In our series, myopericarditis was a benign disease affecting mostly young men, and prognosis was good. A significant proportion of cases was preceded by group A streptococcus infection.

Original research. Regional Wall Motion Abnormalities and Ventricular Function in Acute Peri-Myocarditis

Introduction: Myocardial involvement in pericardial diseases and the effect of pericardial inflammation and effusion on the function of the left ventricle (LV) is still a controversial issue. The present study aimed to evaluate LV regional wall abnormalities in patients with acute peri-myocarditis, using 3D echocardiographic assessment of LV contractility. Material and methods: The study included 56 subjects divided into two groups: Group 1 - 28 subjects with acute peri-myocarditis and Group 2 - 28 healthy controls. All subjects underwent a complete clinical examination, including laboratory tests. 3D echocardiography was performed to assess the left ventricular end-diastolic (EDV) and end-systolic volumes (ESV), and to calculate specific indexes for global and regional ventricular contractility, such as the index of contraction amplitude (ICA) and the regional index of contraction amplitude (RICA) for each segment corresponding to the region affected by peri- myocarditis. Results: 3D echocardiography showed no differences between the groups regarding the EDV (p = 0.2), the LV ejection fraction (Group 1: 55.82% ± 3.36% vs. Group 2: 57.21% ± 4.69%, p = 0.2). The ESV however, was significantly higher in Group 1 compared to Group 2 (55.78 ± 5.45 ml vs. 52.20 ± 6.43 ml, p = 0.04). ICA was similar between the groups (p = 0.2). However, the RICA was significantly lower in Group 1 compared to Group 2 (2.27 ± 0.63 vs. 5.16 ± 0.54, p <0.0001). Conclusions: The extension of the inflammatory process from the pericardium to the adjacent myocardial layer may affect the contractility of the LV. A good association exists between peri-myocarditis and the regional contractility abnormalities of the LV.

European Guidelines on Pericardial Diseases: a Focused Review of Novel Aspects

Pericardial diseases are not uncommon in daily clinical practice. The spectrum of these syndromes includes acute and chronic pericarditis, pericardial effusion, constrictive pericarditis, congenital defects, and neoplasms. The extent of the high-quality evidence on pericardial diseases has expanded significantly since the first international guidelines on pericardial disease management were published by the European Society of Cardiology in 2004. The clinical practice guidelines provide a useful reference for physicians in selecting the best management strategy for an individual patient by summarizing the current state of knowledge in a particular field. The new clinical guidelines on the diagnosis and management of pericardial diseases that have been published by the European Society of Cardiology in 2015 represent such a tool and focus on assisting the physicians in their daily clinical practice. The aim of this review is to outline and emphasize the most clinically relevant new aspects of the current guidelines as compared with its previous version published in 2004.

Prognostic implications of epicardial fat volume quantification in acute pericarditis

BACKGROUND

The pathophysiology of acute pericarditis remains largely unknown, and biomarkers are needed to identify patients susceptible to complications. As adipose tissue has a pivotal role in cardiovascular disease pathogenesis, we hypothesized that quantification of epicardial fat volume (EFV) provides prognostic information in patients with acute pericarditis.

MATERIALS AND METHODS

Fifty (n = 50) patients with first diagnosis of acute pericarditis were enrolled in this study. Patients underwent a cardiac computerized tomography (CT) scan to quantify EFV on a dedicated workstation. Patients were followed up in hospital for atrial fibrillation (AF) development and up to 18 months for the composite clinical endpoint of development of constrictive, recurrent or incessant pericarditis or poor response to nonsteroidal anti-inflammatory drugs.

RESULTS

Patients presenting with chest pain had lower EFV vs. patients without chest pain (167·2 ± 21·7 vs. 105·1 ± 11·1 cm³ , respectively, P < 0·01); EFV (but not body mass index) was strongly positively correlated with pericardial effusion size (r = 0·395, P = 0·007) and associated with in-hospital AF. At follow-up, patients that reached the composite clinical endpoint had lower EFV (P < 0·05). After adjustment for age, EFV was associated with lower odds ratio for the composite clinical endpoint point of poor response to NSAIDs or the development of constrictive, recurrent or incessant pericarditis during follow-up (per 20 cm³ increase in EFV: OR = 0·802 [0·656-0·981], P < 0·05).

CONCLUSIONS

We report for the first time a significant association of EFV with the clinical features and the outcome of patients with acute pericarditis. Measurement of EFV by CT may have important prognostic implications in these patients.

Recent advances in the management of pericardial diseases

Pericardial diseases are relatively common in clinical practice either as isolated diseases or part of an underlying or systemic disease. Recent advances in the diagnosis and treatment have greatly improved the clinical management and lead to consensus documents on multimodality imaging and new guidelines on the diagnosis and therapy of pericardial diseases. The aim of the present paper is to summarize available evidence in order to provide an updated and comprehensive review on the recent advances in the management of pericardial diseases.

Acute Pericarditis-Associated Hospitalization in the USA: A Nationwide Analysis, 2003-2012

BACKGROUND AND OBJECTIVES

Epidemiologic data on hospitalizations for acute pericarditis are scarce. We sought to study the trends in these hospitalizations and outcomes in the USA over a 10-year period.

METHODS

We used the 2003-2012 Nationwide Inpatient Sample database to identify admissions with a primary diagnosis of acute pericarditis. Outcomes included hospitalization rate, case fatality rate (CFR), length of stay (LOS), hospital charges, complications and diagnostic and therapeutic procedures.

RESULTS

We observed an estimated 135,710 hospitalizations for acute pericarditis among patients ≥16 years during the study period (mean age 53.5 ± 18.5 years; 40.5% women). The incidence of acute pericarditis hospitalizations was significantly higher for men than for women [incidence rate ratio (IRR) 1.56; 95% confidence interval (CI) 1.54-1.58; p < 0.001]; it decreased from 66 to 54 per million person-years (p < 0.001). CFR and LOS declined significantly during the study period (CFR: 2.2% in 2003 to 1.4% in 2012; LOS: 4.8 days in 2003 to 4.1 days in 2012; p < 0.001 for both). The average inflation-adjusted health-care charge increased from USD 31,242 to 38,947 (p < 0.001).

CONCLUSION

The hospitalization rate, CFR and LOS associated with acute pericarditis have declined significantly in the US population. Average charges for acute pericarditis hospitalization have increased.

Acute tuberculous myopericarditis mimicking acute myocardial infarction: A case report and literature review

A number of cases of acute myopericarditis mimicking acute myocardial infarction (AMI) have previously been reported in the literature. However, to the best of our knowledge, such a case resulting from Mycobacterium tuberculosis infection has not previously been described. The present study reports the case of a 21-year-old male patient presenting with acute chest pain, in whom focal ST-segment elevation and elevated cardiac enzymes mimicked a diagnosis of AMI. However, acute tuberculous myopericarditis was diagnosed on the basis of a variety of imaging examinations, laboratory tests, as well as the changes observed in electrocardiograms (ECGs) and in the cardiac enzyme levels. The case highlights the importance of a detailed collection of medical history, comprehensive explanations of serial ECGs, thoracic computed tomography, echocardiogram and coronary angiography in the diagnosis and differentiation of acute tuberculous myopericarditis mimicking AMI.

Postmortem diagnosis of infectious heart diseases: A mystifying cause of Sudden Infant Death

Sudden infant death (SID) is an unresolved problem of high relevance and previous studies have indicated a role of viral heart infections. The diagnosis remains difficult in clinical practice using routine diagnostic tests and must be substantially improved. A prospective study based on post-mortem samples from SID victims whose heart disease was not clinically recognized was conducted for 4 years in a Tunisian University Hospital. Pediatric cases of unnatural death served as controls. Both SID victims and controls were investigated for possible coxsackievirus-B (CV-B) infection in heart tissue. During the study period, 39 cases with a male predominance (77%) were reported. There was no positive family history of coronary artery disease among the victims. In 35 cases (90%), low birth weight and/or critical development period were reported. All SID victims had complained of mild fever and insomnia for a few days preceding death, which required infectious laboratory investigations marked with an elevated white blood cell count (WBC) and C-reactive protein (CRP). The cardiac biomarkers were also elevated. The histopathological investigations of the heart tissue samples revealed signs of myocardial and pericardial inflammation. Enterovirus was detected by immunohistochemistry (IHC) and PCR from myocardial samples from 6 cases (15.3%) having myocarditis and 3 cases (7.7%) having perimyocarditis. The current study is of great interest and is aimed at urging health professionals to adopt systematically long intensive heart care in infants with underlying vulnerability as well as new diagnostic approaches including histopathology complemented with IHC and molecular pathology.

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

Purpose—

To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.

Methods—

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

Results—

After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.

Pharmacotherapy update of acute idiopathic pericarditis

Idiopathic (viral) pericarditis is the most common form of pericardial disease in the Western world. Despite the combination of colchicine and nonsteroidal antiinflammatory drugs (NSAIDs) plus aspirin (ASA), considered first-line therapy, the incidence of recurrent pericarditis is ~20-30%. In addition, secondary recurrence without optimal first-line therapy is ~50%. This is due to the many clinical challenges, such as inappropriate NSAID/ASA duration of therapy, the use of corticosteroid therapy, contraindications or intolerances to therapy, adverse effects, and issues related to adherence. This review describes contemporary pharmacotherapeutic management of idiopathic (viral) pericarditis, with a particular emphasis on the role of colchicine. Emerging therapies and management strategies, such as high-sensitivity C-reactive protein-guided therapy and novel immunotherapies, are also reviewed. Ultimately, understanding appropriate treatment will assist the clinician in helping decrease the risk of recurrent, incessant, and refractory pericarditis.

Influence of different aetiologies on clinical course and outcome in patients with dilated cardiomyopathy

BACKGROUND

The clinical phenotype dilated cardiomyopathy is assumed to be the endstage of a multifactorial aetiopathogenetic pathophysiology which includes a not satisfactorily defined group of patients with inflammatory cardiomyopathy.

METHODS

Within the German Competence Network Heart Failure patients with heart failure due to dilated cardiomyopathy of viral/inflammatory (DCMi/v) and nonviral/noninflammatory (DCM) aetiology were enrolled. After 1 year 237 patients (180 male/57 female) were re-examined including complete clinical work-up. The association of different clinical courses with the time from initial diagnosis of heart failure (newly: ≤ 1 year; late: > 1 year) was investigated.

RESULTS

After 1-year-follow-up New York Heart Association (NYHA) class (by -0.48 in newly diagnosed DCM and -0.82 in newly diagnosed DCMi/v in addition to -0.24 in late diagnosed DCM and -0.17 in late diagnosed DCMi/v) as well as left ventricular ejection fraction (+14% in newly diagnosed DCM and DCMi/v and +6% in later diagnosed DCM and DCMi/v) were significantly improved in all patients. In patients with early diagnosed dilated cardiomyopathy a strong improvement of NYHA class could be demonstrated.

CONCLUSIONS

This study demonstrates for the first time a significant interaction between duration of disease, NYHA class and left ventricular ejection fraction in patients with DCM. Our results clearly demonstrate that in patients with DCM an early diagnosis within 1 year after occurrence of clinical signs is associated with a strong improvement in the clinical course, whereas late diagnosis results in a loss of change in clinical course and outcome.

Incidence and prognostic significance of new onset atrial fibrillation/flutter in acute pericarditis

OBJECTIVE

Data on the incidence of new onset atrial fibrillation and flutter (AF/f) in patients with acute pericarditis are limited. We sought to determine the incidence and prognostic significance of AF/f in this setting.

METHODS

Between January 2006 and June 2014, consecutive new cases of acute pericarditis were included in two urban referral centres for pericardial diseases. All new cases of AF/f defined as episodes lasting ≥30 s were recorded. Events considered during follow-up consisted of AF/f and pericarditis recurrence, cardiac tamponade, pericardial constriction and death.

RESULTS

822 consecutive new cases of acute pericarditis (mean age 53±15 years, 444 men) were analysed. AF/f was detected in 35 patients (4.3%, mean age 66.5±11.3 years, 18 men). Patients with AF/f were significantly older (p=0.017) and presented more frequently with pericardial effusion (p<0.001). Arrhythmias developed within 24 h of pericarditis onset in 91.4% of cases, lasted >24 h in 25.7% and spontaneously converted in 74.3% of patients. Underlying structural heart disease was present in 17% of AF/f cases. In a 30-month follow-up, patients with history of AF/f at the initial episode had a higher rate of arrhythmia occurrence (34.3% vs 0.9%, p<0.001), mostly (75%) within 3 months. No other differences were detected in additional clinical events including haemorrhagic complications in patients receiving oral anticoagulation.

CONCLUSIONS

The occurrence of AF/f in acute pericarditis identifies a predisposed population to AF/f with a high recurrence risk (about 35%): in these patients, pericarditis may act as an arrhythmic trigger and oral anticoagulation should be seriously considered according to guidelines.

Pericarditis and pericardial effusions in the military patient

The pericardium is the thin double-walled sac encapsulating the heart which has a number of important physiological roles including fixing the heart in the mediastinum, protecting it from cross-organ infection (eg, lung) and lubricating cardiac contraction. The pericardium is associated with several disease syndromes that occasionally affect the military population. These include acute and recurrent pericarditis, pericardial effusion and tamponade, which may result from a large number of different aetiological agents. Pericardial diseases have a wide range of clinical manifestations and the diagnosis of pericardial diseases can be a challenge. This article reviews the anatomy and pathophysiology of pericarditis and pericardial effusions before outlining their clinical features, recommended investigations and management options. Particular emphasis is placed on the impact of these diseases for patients in a military occupational environment.

Prognosis of myopericarditis as determined from previously published reports

BACKGROUND

The prognosis of pericarditis with concomitant myocarditis, especially in the setting of troponin elevation, is a reason for concern because it could imply an adverse outcome.

METHODS

We performed a comprehensive Medline search of all publications from 2000 to 2013 with the MeSH terms 'pericarditis', 'myocarditis' and 'prognosis'. Additional publications were sought using the reference lists of identified papers, the published reviews on this topic, and a search of abstracts from the American Heart Association, American College of Cardiology, and European Society of Cardiology scientific sessions.

RESULTS

We identified eight major clinical series evaluating the prognosis of myopericarditis. Studies included a total of 389 patients with myopericarditis (mean age 31.7 years, men-to-women ratio 4.0). After a mean follow-up of 31 months, residual left-ventricular dysfunction was reported in 3.5% without cases of heart failure. Recurrences occurred in 13.0% of cases mainly as recurrent pericarditis (>90%), cardiac tamponade and constrictive pericarditis in less than 1% of cases. The overall prognosis seems good (no mortality), with only one single discordant study reporting three deaths: one related to cardiac tamponade and two sudden cardiac deaths during hospitalization, but no out-of-hospital deaths during follow-up.

CONCLUSION

Myopericarditis has a good overall prognosis. Troponin elevation in this setting does not predict an adverse outcome in most cases. Thus it is important to reassure the patients on their prognosis, explaining the nature of the disease and the likely course. Diagnostic and therapeutic choices should take into account the overall good outcome of these patients, including less invasive diagnostic tools and toxic drugs.

Arrhythmias in viral myocarditis and pericarditis

Acute viral myocarditis and acute pericarditis are self-limiting conditions that run a benign course and that may not involve symptoms that lead to medical assessment. However, ventricular arrhythmia is frequent in viral myocarditis. Myocarditis is thought to account for a large proportion of sudden cardiac deaths in young people without prior structural heart disease. Identification of acute myocarditis either with or without pericarditis is therefore important. However, therapeutic interventions are limited and nonspecific. Identifying those at greatest risk of a life-threatening arrhythmia is critical to reducing the mortality. This review summarizes current understanding of this challenging area in which many questions remain.

Probable hydrochlorothiazide-induced myopericarditis: first case reported

Hydrochlorothiazide has never been reported as a reason for myopericarditis. An African American female, with past history of hypertension, coronary artery disease, and sulfa allergy, presented with indolent onset and retrosternal chest pain which was positional, pleuritic, and unresponsive to sublingual nitroglycerin. Her medications included hydrochlorothiazide (HCTZ) which was started three months ago for uncontrolled hypertension. Significant laboratory parameters included erythrocyte sedimentation rate (ESR) of 47 mm/hr and peak troponin of 0.26 ng/mL. Transthoracic echocardiogram (TTE) revealed preserved ejection fraction with no segmental wall motion abnormalities; however, it showed moderate pericardial effusion without tamponade physiology. We hypothesize that this myopericarditis could be due to HCTZ allergic reaction after all other common etiologies have been ruled out. There is a scarcity of the literature regarding HCTZ as an etiology for pericardial disease, with only one case reported as presumed hydrochlorothiazide-induced pericardial effusion. Management involves discontinuation of HCTZ and starting anti-inflammatory therapy.