2015 ESC Guidelines on the diagnosis and management of pericardial diseases

2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)
Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS).
Eur Heart J. 2015 Nov 7;36(42):2921-64. doi: 10.1093/eurheartj/ehv318. Epub 2015 Aug 29. PubMed PMID: 26320112.

Presented by Massimo Imazio, MD, FESC, Cardiology Department, Maria Vittoria Hospital and Department of Public Health and Paediatrics, University of Torino, Torino, Italy.

Authors/Task Force Members: Adler Y, Charron P, et al.

The 2015 ESC guidelines on the diagnosis and management of pericardial diseases (1) represent totally new guidelines and not simply an update of the previous ones issued in 2004 (2).

The main focus of the current guidelines is clinical management of pericardial diseases.

A substantial huge amount of new data have become available in the last 10 years: first multicentre RCTs, first epidemiological and observational studies with> 100 patients have been published soliciting new guidelines.

The main 10 new things that have been published and will affect contemporary management of these diseases include:

1. Probabilistic and epidemiological approach to the aetiology. Pericardial diseases may be caused by a wide range of causes but there are main aetiologies that should be especially ruled out: tuberculosis (the most common cause of pericardial diseases all over the world and especially relevant in developing countries), cancer, systemic inflammatory diseases, post-cardiac injury syndromes.

2. Statement of definitions and diagnostic criteria for acute and recurrent pericarditis (see table 1). Such definitions and criteria will help the clinicians to establish the diagnosis but also will help to standardize the terminology for future studies and research.

Table 1. Diagnostic criteria and definitions

3. New role of markers of inflammation (especially C-reactive protein) to confirm the diagnosis and monitor the activity of the disease: this will help to individualize the therapy and provide duration of the anti-inflammatory therapy till symptoms resolution and normalization of C-reactive protein.

4. New role of imaging to assess pericardial inflammation. Pericardial inflammation can be identified by CT (contrast-enhancement of the inflamed pericardium) but especially by CMR that allows detecting pericardial oedema on T2-weighted imaging and pericardial late gadolinium enhancement as expression of organizing pericarditis. In atypical of doubtful presentations this will allow reaching the diagnosis of pericarditis.

5. Triage of pericarditis. Specific features at presentation have been identified as major poor prognostic predictors (fever>38°C, subacute course, large pericardial effusion, cardiac tamponade, lack of response to empiric anti-inflammatory therapy) that could be helpful to identify patients at high risk of complications and non-idiopathic or non-viral aetiologies to be admitted and investigated. Additional features may require monitoring: associated myocarditis, immunodepression or immunosuppression, trauma, and oral anticoagulant therapy. Low risk cases without these features can be managed as outpatient.

6. New therapeutic schemes and dosing for acute pericarditis. High doses of anti-inflammatory every 8 hours till symptoms resolution and C-reactive protein normalization will help to improve remission rates and reduce recurrences especially with the adjunct of colchicine on top of standard anti-inflammatory therapies (table 2).

Table 2. Therapeutic schemes for acute pericarditis

7. Therapeutic algorhytm for recurrent pericarditis. Aspirin and NSAID plus colchicine are mainstay of therapy for acute and recurrent pericarditis. Corticosteroids are a second option to be considered in patients not responding to first line therapies or for specific indications (e.g. pregnancy, systemic inflammatory diseases already on corticosteroids). In cases that do not respond to these therapies or a combination of them, emerging options are highlighted: azathioprine, IVIG, and anakinra. Pericardiectomy is the last option in experienced centres (Figure 1).

8. Triage of pericardial effusion. In cases with cardiac tamponade or a suspicion of a bacterial or neoplastic aetiology pericardiocentesi is indicated as well as admission. Otherwise a triage is proposed considering the presence of a missed diagnosis of pericarditis, the presence of an underlying systemic disease as a cause of the effusion (up to 60% of these cases), and the size and duration of the effusion. Large (>20mm) and chronic (>3 months) pericardial effusions may progress to cardiac tamponade in case of pericarditis or trauma. Thus, pericardiocentesis should be considered for these patients without pericarditis or another cause of the effusion (Figure 2).

 9. Transient constrictive pericarditis. New-onset constrictive pericarditis may be transient and cured by empiric anti-inflammatory therapy in case of pericarditis (e.g. evidence of elevated C-reactive protein or pericardial inflammation on imaging) thus preventing pericardiectomy.

10. Specific management issues for children and pregnancy. Specific indications, contraindications and therapeutic schemes are proposed for children, pregnant women but also elderly and in case of hepatic or renal disease.

In conclusion these new guidelines will promote a more evidence-based management of pericardial disease and will assist the clinician in everyday clinical practice.