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{{Pericarditis}}
{{Pericarditis}}
{{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar, M.B.B.S.]]
{{CMG}}; {{AE}}[[Varun Kumar, M.B.B.S.]]{{Homa}}


==Overview==
==Overview==
Line 21: Line 21:


==Autoimmune Markers==
==Autoimmune Markers==
Autoimmune markers may be checked in patients with recurrent disease.
Following [[autoimmune]] markers may be checked in patients with recurrent or prolonged [[pericarditis]]:
*[[Antistreptolysin O titre]]
*[[Rheumatoid factor]] ([[RF]])
*[[Antinuclear antibody]] ([[ANA]])
*[[Anti-dsDNA antibody]]


==Gallium-67 Imaging==
==2015 ESC Guidelines on the Diagnosis and Treatment of Pericarditis (DO NOT EDIT)<ref name="AdlerCharron2015">{{cite journal|last1=Adler|first1=Yehuda|last2=Charron|first2=Philippe|last3=Imazio|first3=Massimo|last4=Badano|first4=Luigi|last5=Barón-Esquivias|first5=Gonzalo|last6=Bogaert|first6=Jan|last7=Brucato|first7=Antonio|last8=Gueret|first8=Pascal|last9=Klingel|first9=Karin|last10=Lionis|first10=Christos|last11=Maisch|first11=Bernhard|last12=Mayosi|first12=Bongani|last13=Pavie|first13=Alain|last14=Ristić|first14=Arsen D.|last15=Sabaté Tenas|first15=Manel|last16=Seferovic|first16=Petar|last17=Swedberg|first17=Karl|last18=Tomkowski|first18=Witold|title=2015 ESC Guidelines for the diagnosis and management of pericardial diseases|journal=European Heart Journal|volume=36|issue=42|year=2015|pages=2921–2964|issn=0195-668X|doi=10.1093/eurheartj/ehv318}}</ref>==
Gallium-67 scanning may help identify inflammatory and [[leukemic]] infiltrations.


==Diagnositic [[Pericardiocentesis]]==
===Recommendations for the general diagnostic work-up of pericardial diseases===
Pericardial fluid should be aspirated and tested for presence of malignant cells and tumor markers particularly in patients with hemorrhagic effusion without preceding trauma<ref name="pmid10593777">{{cite journal| author=Atar S, Chiu J, Forrester JS, Siegel RJ| title=Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s? | journal=Chest | year= 1999 | volume= 116 | issue= 6 | pages= 1564-9 | pmid=10593777 | doi= | pmc= | url= }} </ref>. However, hemorrhagic pericarditis in developing countries could be due to [[tuberculosis]]. Sensitivity of [[cytology|cytological]] analysis of pericardial fluid for malignant cells were 67%<ref name="pmid2028688">{{cite journal| author=Wiener HG, Kristensen IB, Haubek A, Kristensen B, Baandrup U| title=The diagnostic value of pericardial cytology. An analysis of 95 cases. | journal=Acta Cytol | year= 1991 | volume= 35 | issue= 2 | pages= 149-53 | pmid=2028688 | doi= | pmc= | url= }} </ref>, 75%<ref name="pmid10554845">{{cite journal| author=Porte HL, Janecki-Delebecq TJ, Finzi L, Métois DG, Millaire A, Wurtz AJ| title=Pericardoscopy for primary management of pericardial effusion in cancer patients. | journal=Eur J Cardiothorac Surg | year= 1999 | volume= 16 | issue= 3 | pages= 287-91 | pmid=10554845 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10554845  }} </ref> and 92%<ref name="pmid9149572">{{cite journal| author=Meyers DG, Meyers RE, Prendergast TW| title=The usefulness of diagnostic tests on pericardial fluid. | journal=Chest | year= 1997 | volume= 111 | issue= 5 | pages= 1213-21 | pmid=9149572 | doi= | pmc= | url= }} </ref> in different studies with specificity of 100%. [[Immunohistochemistry]] can be used to distinguish between the malignant cells and their possible origin<ref name="pmid12508174">{{cite journal| author=Gong Y, Sun X, Michael CW, Attal S, Williamson BA, Bedrossian CW| title=Immunocytochemistry of serous effusion specimens: a comparison of ThinPrep vs cell block. | journal=Diagn Cytopathol | year= 2003 | volume= 28 | issue= 1 | pages= 1-5 | pmid=12508174 | doi=10.1002/dc.10219 | pmc= | url= }} </ref><ref name="pmid9068950">{{cite journal| author=Mayall F, Heryet A, Manga D, Kriegeskotten A| title=p53 immunostaining is a highly specific and moderately sensitive marker of malignancy in serous fluid cytology. | journal=Cytopathology | year= 1997 | volume= 8 | issue= 1 | pages= 9-12 | pmid=9068950 | doi= | pmc= | url= }} </ref>.


Fluid aspirated can also be used for following tests:
{|class="wikitable"
*[[Gram staining]]
|-
*[[Acid-fast]] staining
| colspan="1" style="text-align:center; background:LightGreen"|[[ESC Guidelines Classification Scheme#Classification of Recommendations|Class I]]
*Culture
|-
| bgcolor="LightGreen"|<nowiki></nowiki>'''1.''' In all cases of suspected [[pericardial disease]] a first [[diagnostic]] evaluation is recommended with:
– [[auscultation]]


==Pericardial Biopsy==
– [[ECG]]
If the clinical suspicion of malignancy is high, and if the results of cytology testing from the pericardiocentesis are negative, consideration should be given to performing a pericardial biopsy. This can be performed via either a subxiphoid or transthoracic [[pericardiostomy]] or alternatively by [[pericardioscopy]]. An advantage of pericardioscopy is that it assists in the direct visualization of pericardium and collecting the biopsy sample. Pericardioscopy has an excellent sensitivity of 97%<ref name="pmid10554845">{{cite journal| author=Porte HL, Janecki-Delebecq TJ, Finzi L, Métois DG, Millaire A, Wurtz AJ| title=Pericardoscopy for primary management of pericardial effusion in cancer patients. | journal=Eur J Cardiothorac Surg | year= 1999 | volume= 16 | issue= 3 | pages= 287-91 | pmid=10554845 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10554845  }} </ref><ref name="pmid8840855">{{cite journal| author=Nugue O, Millaire A, Porte H, de Groote P, Guimier P, Wurtz A et al.| title=Pericardioscopy in the etiologic diagnosis of pericardial effusion in 141 consecutive patients. | journal=Circulation | year= 1996 | volume= 94 | issue= 7 | pages= 1635-41 | pmid=8840855 | doi= | pmc= | url= }} </ref> which compares quite favorably to a blind biopsy which has a low sensitivity of 55-65%.
 
– [[transthoracic echocardiography]]
 
– [[chest X-ray]]
 
– routine [[blood tests]], including markers of [[inflammation]] (i.e., [[CRP]] and/or [[ESR]]), white [[blood cell count]] with differential count, [[renal function]] and [[Liver function tests|liver tests]] and [[myocardial]] [[Lesions|lesion]] [[Test|tests]] ([[CK]], [[Troponin|troponins]]).
 
'''2.''' [[CT]] and/or [[CMR]] are recommended as [[second]]-level [[testing]] for [[diagnostic]] workup in pericarditis.
 
'''3.''' [[Pericardiocentesis]] or [[Drain (surgery)|surgical drainage]] are [[Indication (medicine)|indicated]] for [[cardiac tamponade]] or suspected [[bacterial]] and [[neoplastic pericarditis]].
 
'''4.''' Further testing is [[Indication (medicine)|indicated]] in high-risk [[patients]] (defined as above) according to the [[clinical]] [[conditions]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''
 
''<nowiki/>''
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESC Guidelines Classification Scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki></nowiki>It is recommended to search for independent predictors of an identifiable and specifically treatable cause of pericarditis (i.e. [[bacterial]], [[neoplastic]], [[systemic]] [[inflammatory diseases]]). Major factors include:
– [[fever]] >38 C
 
– [[subacute]] [[Course (medicine)|course]] ([[symptoms]] developing over several days or weeks)
 
– large [[pericardial effusion]] ([[diastolic]] echo-free space >20 mm in width)
 
– [[cardiac tamponade]]
 
– [[failure]] of [[Aspirin]] or [[NSAIDs]] ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])<ref name="ImazioDemichelis2004">{{cite journal|last1=Imazio|first1=Massimo|last2=Demichelis|first2=Brunella|last3=Parrini|first3=Iris|last4=Giuggia|first4=Marco|last5=Cecchi|first5=Enrico|last6=Gaschino|first6=Gianni|last7=Demarie|first7=Daniela|last8=Ghisio|first8=Aldo|last9=Trinchero|first9=Rita|title=Day-hospital treatment of acute pericarditis|journal=Journal of the American College of Cardiology|volume=43|issue=6|year=2004|pages=1042–1046|issn=07351097|doi=10.1016/j.jacc.2003.09.055}}</ref><ref name="ImazioCecchi2007">{{cite journal|last1=Imazio|first1=Massimo|last2=Cecchi|first2=Enrico|last3=Demichelis|first3=Brunella|last4=Ierna|first4=Salvatore|last5=Demarie|first5=Daniela|last6=Ghisio|first6=Aldo|last7=Pomari|first7=Franco|last8=Coda|first8=Luisella|last9=Belli|first9=Riccardo|last10=Trinchero|first10=Rita|title=Indicators of Poor Prognosis of Acute Pericarditis|journal=Circulation|volume=115|issue=21|year=2007|pages=2739–2744|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.106.662114}}</ref>''
 
''<nowiki/>''
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESC guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon" |<nowiki></nowiki>  [[Percutaneous]] or [[surgical]] [[pericardial]] [[biopsy]] may be considered in selected cases of suspected [[neoplastic]] or [[tuberculous pericarditis]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence:]]<nowiki/> [[ACC AHA Guidelines Classification Scheme#Level of Evidence|C]])''
|}
 
 
===Recommendations for diagnosis of acute pericarditis===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESC Guidelines Classification Scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki></nowiki>'''1.'''  [[ECG]] is recommended in all [[patients]] with suspected [[acute pericarditis]].
 
'''2.''' [[Transthoracic echocardiography]] is recommended in all [[patients]] with suspected [[acute pericarditis]].
 
'''3.''' [[Chest X-rays|Chest X-ray]] is recommended in all [[patients]] with suspected [[Acute pericarditis|acute pericarditis.]]
 
'''4.''' Assessment of markers of [[inflammation]] (i.e. [[CRP]]) and [[myocardial]] [[injury]] (i.e. [[CK]], [[troponin]]) is recommended in [[patients]] with suspected [[acute pericarditis]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''
 
''<nowiki/>''
|}
 
===Recommendations for the diagnosis and therapy of viral pericarditis===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESC guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon" |<nowiki></nowiki> For the definited [[diagnosis]] of [[viral pericarditis]], a comprehensive workup of [[histological]], [[cytological]], [[Immunohistochemistry|immunohistological]] and [[molecular]] investigations in [[pericardial fluid]] and peri-/[[epicardial]] [[biopsies]] should be considered. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]]<nowiki/>)''
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ESC guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|bgcolor="LightCoral" |<nowiki></nowiki> '''1.''' Routine [[viral]] [[serology]] is not recommended, with the possible exception of [[Human Immunodeficiency Virus (HIV)|HIV]] and [[Hepatitis C|HCV]].
'''2.''' [[Corticosteroid]] [[therapy]] is not recommended in [[viral pericarditis]]. (''[[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''
 
''<nowiki/>''
|}
 
===Recommendations for the diagnosis of purulent pericarditis===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESC Guidelines Classification Scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki></nowiki>'''1.'''  [[Urgent care|Urgent]] [[pericardiocentesis]] is recommended for the [[diagnosis]] of [[purulent pericarditis]].
 
'''2.''' It is recommended that [[pericardial fluid]] be sent for [[bacterial]], [[fungal]] and [[tuberculous]] studies and [[blood]] drawn for cultures. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''
 
''<nowiki/>''
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}


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Latest revision as of 23:39, 29 July 2020

Pericarditis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. Homa Najafi, M.D.[2]

Overview

Non-specific markers of inflammation are generally elevated in pericarditis. These include the leukocyte count, C-reactive protein, and ESR. The cardiac troponin is elevated if there is an injury to the underlying myocardium, a condition termed as myopericarditis. Diagnostic pericardiocentesis and biopsy help in identifying an underlying infectious or malignant process.

Inflammatory Markers

The following inflammatory markers are often elevated:

Cardiac Biomarkers

The following markers of myonecrosis may be elevated if there is involvement of the underlying myocardium:

Autoimmune Markers

Following autoimmune markers may be checked in patients with recurrent or prolonged pericarditis:

2015 ESC Guidelines on the Diagnosis and Treatment of Pericarditis (DO NOT EDIT)[5]

Recommendations for the general diagnostic work-up of pericardial diseases

Class I
1. In all cases of suspected pericardial disease a first diagnostic evaluation is recommended with:

– auscultation

– ECG

– transthoracic echocardiography

– chest X-ray

– routine blood tests, including markers of inflammation (i.e., CRP and/or ESR), white blood cell count with differential count, renal function and liver tests and myocardial lesion tests (CK, troponins).

2. CT and/or CMR are recommended as second-level testing for diagnostic workup in pericarditis.

3. Pericardiocentesis or surgical drainage are indicated for cardiac tamponade or suspected bacterial and neoplastic pericarditis.

4. Further testing is indicated in high-risk patients (defined as above) according to the clinical conditions. (Level of Evidence: C)

Class I
It is recommended to search for independent predictors of an identifiable and specifically treatable cause of pericarditis (i.e. bacterial, neoplastic, systemic inflammatory diseases). Major factors include:

– fever >38 C

– subacute course (symptoms developing over several days or weeks)

– large pericardial effusion (diastolic echo-free space >20 mm in width)

– cardiac tamponade

– failure of Aspirin or NSAIDs (Level of Evidence: B)[6][7]

Class IIb
Percutaneous or surgical pericardial biopsy may be considered in selected cases of suspected neoplastic or tuberculous pericarditis. (Level of Evidence: C)


Recommendations for diagnosis of acute pericarditis

Class I
1. ECG is recommended in all patients with suspected acute pericarditis.

2. Transthoracic echocardiography is recommended in all patients with suspected acute pericarditis.

3. Chest X-ray is recommended in all patients with suspected acute pericarditis.

4. Assessment of markers of inflammation (i.e. CRP) and myocardial injury (i.e. CK, troponin) is recommended in patients with suspected acute pericarditis. (Level of Evidence: C)

Recommendations for the diagnosis and therapy of viral pericarditis

Class IIa
For the definited diagnosis of viral pericarditis, a comprehensive workup of histological, cytological, immunohistological and molecular investigations in pericardial fluid and peri-/epicardial biopsies should be considered. (Level of Evidence: C)
Class III
1. Routine viral serology is not recommended, with the possible exception of HIV and HCV.

2. Corticosteroid therapy is not recommended in viral pericarditis. (Level of Evidence: C)

Recommendations for the diagnosis of purulent pericarditis

Class I
1. Urgent pericardiocentesis is recommended for the diagnosis of purulent pericarditis.

2. It is recommended that pericardial fluid be sent for bacterial, fungal and tuberculous studies and blood drawn for cultures. (Level of Evidence: C)

References

  1. ↑ Spodick DH (2003). "Acute pericarditis: current concepts and practice". JAMA. 289 (9): 1150–3. doi:10.1001/jama.289.9.1150. PMID 12622586.
  2. ↑ Karjalainen J, Heikkila J (1986). ""Acute pericarditis": myocardial enzyme release as evidence for myocarditis". Am Heart J. 111 (3): 546–52. doi:10.1016/0002-8703(86)90062-1. PMID 3953365.
  3. ↑ Bonnefoy E, Godon P, Kirkorian G, Fatemi M, Chevalier P, Touboul P (2000). "Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis". Eur Heart J. 21 (10): 832–6. doi:10.1053/euhj.1999.1907. PMID 10781355.
  4. ↑ Imazio M, Demichelis B, Cecchi E, Belli R, Ghisio A, Bobbio M, Trinchero R (2003). "Cardiac troponin I in acute pericarditis". J Am Coll Cardiol. 42 (12): 2144–8. doi:10.1016/j.jacc.2003.02.001. PMID 14680742.
  5. ↑ Adler, Yehuda; Charron, Philippe; Imazio, Massimo; Badano, Luigi; Barón-Esquivias, Gonzalo; Bogaert, Jan; Brucato, Antonio; Gueret, Pascal; Klingel, Karin; Lionis, Christos; Maisch, Bernhard; Mayosi, Bongani; Pavie, Alain; Ristić, Arsen D.; Sabaté Tenas, Manel; Seferovic, Petar; Swedberg, Karl; Tomkowski, Witold (2015). "2015 ESC Guidelines for the diagnosis and management of pericardial diseases". European Heart Journal. 36 (42): 2921–2964. doi:10.1093/eurheartj/ehv318. ISSN 0195-668X.
  6. ↑ Imazio, Massimo; Demichelis, Brunella; Parrini, Iris; Giuggia, Marco; Cecchi, Enrico; Gaschino, Gianni; Demarie, Daniela; Ghisio, Aldo; Trinchero, Rita (2004). "Day-hospital treatment of acute pericarditis". Journal of the American College of Cardiology. 43 (6): 1042–1046. doi:10.1016/j.jacc.2003.09.055. ISSN 0735-1097.
  7. ↑ Imazio, Massimo; Cecchi, Enrico; Demichelis, Brunella; Ierna, Salvatore; Demarie, Daniela; Ghisio, Aldo; Pomari, Franco; Coda, Luisella; Belli, Riccardo; Trinchero, Rita (2007). "Indicators of Poor Prognosis of Acute Pericarditis". Circulation. 115 (21): 2739–2744. doi:10.1161/CIRCULATIONAHA.106.662114. ISSN 0009-7322.

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