Acute Pericarditis

Management of acute pericarditis

PURPOSE OF REVIEW

Provide an update on current management and most recent evidence in the treatment of pediatric pericarditis.

RECENT FINDINGS

While treatment of acute pericarditis has not significantly changed over the last decade, management of recurrent acute pericarditis, with increased attention to autoinflammation as a causal mechanism, has evolved substantially. This includes clinical trial evidence that newer medications targeting interleukin-1 receptors are effective in recurrent forms of pericarditis. In addition, advanced imaging utilizing cardiac magnetic resonance has emerged as a particularly effective way to detect ongoing pericardial inflammation in support of more difficult-to-treat patients.

SUMMARY

Recent advances in acute and recurrent pericarditis management have allowed for a more tailored approach to the individual patient. Yet, unresolved questions require further research.

Relapsing pericarditis: Peripheral blood neutrophilia, lymphopenia and high neutrophil-to-lymphocyte ratio herald acute attacks, high-grade inflammation, multiserosal involvement, and predict multiple recurrences

AIMS

To identify peripheral blood cellular correlates of active pericarditis and to verify whether peripheral blood neutrophils, lymphocytes and the neutrophil to-lymphocyte ratio (NLR) are associated with disease phenotype or prognosis.

METHODS

Observational prospective study on a cohort of 63 patients with idiopathic pericarditis followed for 12 months after each pericarditis recurrence. Two distinct analyses were performed: the "index attack" analysis focused on the first pericarditis episode in each patient, while the "all attacks" analysis included all episodes occurring during the study.

RESULTS

Absolute and relative neutrophilia and lymphopenia, together with high NLR, were observed during active pericarditis, as compared with disease remission, at both analyses. Neutrophils showed a positive correlation with plasma C-reactive protein levels, while lymphocyte count showed a negative correlation. Relative neutrophil count was higher, and lymphocyte count lower in patients with pleural effusion; a higher NLR and lower absolute lymphocyte count were observed in those with peritoneal involvement. No correlations were found between peripheral blood neutrophil or lymphocyte counts and size of pericardial effusion, or with the presence of myocardial involvement. Peripheral neutrophilia, lymphopenia and NLR during acute attacks predicted the number of recurrences in the following 12 months.

CONCLUSIONS

Peripheral blood neutrophilia and lymphopenia are typical of acute idiopathic pericarditis. Acute attacks of pericarditis are associated with neutrophilia and lymphopenia, as compared with disease remission. During acute attacks, neutrophilia and lymphopenia reflect the extent of serosal inflammation and could help to customize therapeutic management after remission has been achieved.

NLRP3-mediated inflammation in cardio-oncology: sterile yet harmful

Despite significant advances and the continuous development of novel, effective therapies to treat a variety of malignancies, cancer therapy-induced cardiotoxicity has been identified as a prominent cause of morbidity and mortality, closely competing with secondary malignancies. This unfortunate limitation has prompted the inception of the field of cardio-oncology with its purpose to provide the necessary knowledge and key information on mechanisms that support the use of the most efficacious cancer therapy with minimal or no interruption while paying close attention to preventing cardiovascular related morbidity and mortality. Several mechanisms that contribute to cancer therapy-induced cardiotoxicity have been proposed and studied. These mainly involve mitochondrial dysfunction and reactive oxygen species-induced oxidative stress, lysosomal damage, impaired autophagy, cell senescence, DNA damage, and sterile inflammation with the formation and activation of the NLRP3 inflammasome. In this review, we focus on describing the principal mechanisms for different classes of cancer therapies that lead to cardiotoxicity involving the NLRP3 inflammasome. We also summarize current evidence of cardio-protection with inflammasome inhibitors in the context of heart disease in general, and further highlight the potential application of this evidence for clinical translation in at risk patients for the purpose of preventing cancer therapy associated cardiovascular morbidity and mortality.

[STEMI mimics : ST elevations on ECG: alternative diagnoses to acute coronary occlusion]

BACKGROUND

The electrocardiogram (ECG) is an integral part of basic emergency medical diagnosis and preoperative evaluation. In cases of ST elevation myocardial infarction (STEMI) immediate treatment is mandatory after correlation of ischemic symptoms with the ECG pattern. However, there are also ECG patterns that can imitate STEMI, possibly resulting in the true underlying diagnosis being missed and inappropriate therapy being initiated.

OBJECTIVES

This paper provides an overview of the most important diagnoses that can imitate STEMI on ECG.

MATERIAL AND METHODS

A literature search was carried out to determine the most important differential diagnoses of ST elevation on ECG. These STEMI mimics are discussed in detail and their relevance for emergency medicine is explained.

RESULTS

This article provides an overview of differential diagnoses that should be known in emergency medicine when assessing an ECG with ST elevations.

CONCLUSION

Good knowledge of the ECG patterns presented here can support decision-making in emergency medicine.

All that Glitters is not Cholecystitis. A Rare Presentation of Acute Pericarditis Mimicking Cholecystitis and Review of the Literature

Acute pericarditis is the most common inflammatory disorder of the pericardium, responsible for approximately 5% of visits to the emergency departments, concerning chest pain without myocardial infarction. We report a case of a 41-year-old man who presented to our hospital, complaining about retrosternal and epigastrium pain. The transthoracic echocardiogram showed pericardial effusion while the electrocardiogram and laboratory findings revealed acute pericarditis. An abdominal ultrasound revealed gallbladder edema. The pericardial effusion was treated with pericardial catheter insertion, diuretics, and nonsteroidal anti-inflammatory drugs. This case shows that acute pericarditis can be clinically presented with many ways, one of them being gallbladder edema. Furthermore, in this case-based review we present all cases of simultaneous appearance of pericarditis and acalculous cholecystitis or gallbladder edema.

Disentangling a Thorny Issue: Myocarditis and Pericarditis Post COVID-19 and Following mRNA COVID-19 Vaccines

Considering the clinical significance for myocarditis and pericarditis after immunization with mRNA COVID-19 vaccines, the present pharmacovigilance study aimed to describe these events reported with mRNA COVID-19 vaccines in the Vaccine Adverse Events Reporting System (VAERS). From 1990 to July 2021, the mRNA vaccines were the most common suspected vaccines related to suspected cases of myocarditis and/or pericarditis (myocarditis: N = 1,165; 64.0%; pericarditis: N = 743; 55.1%), followed by smallpox vaccines (myocarditis: N = 222; 12.2%; pericarditis: N = 200; 14.8%). We assessed all suspected cases through the case definition and classification of the Brighton Collaboration Group, and only definitive, probable, and possible cases were included in the analysis. Our findings suggested that myocarditis and pericarditis mostly involve young male, especially after the second dose with a brief time to onset. Nevertheless, this risk is lower (0.38/100,000 vaccinated people; 95% CI 0.36–0.40) than the risk of developing myocarditis after SARS-CoV-2 infection (1000–4000 per 100,000 people) and the risk of developing “common” viral myocarditis (1–10 per 100,000 people/year). Comparing with the smallpox vaccine, for which is already well known the association with myocarditis and pericarditis, our analysis showed a lower probability of reporting myocarditis (ROR 0.12, 95% CI 0.10–0.14) and pericarditis (ROR 0.06, 95% CI 0.05–0.08) following immunization with mRNA COVID-19 vaccines.

Carditis After COVID-19 Vaccination With a Messenger RNA Vaccine and an Inactivated Virus Vaccine : A Case-Control Study

BACKGROUND

Case reports of carditis after BNT162b2 vaccination are accruing worldwide.

OBJECTIVE

To examine the association of BNT162b2 and CoronaVac (Sinovac) vaccination with carditis.

DESIGN

Case-control study with hospital control participants.

SETTING

Territory-wide, public health care database with linkage to population-based vaccination records in Hong Kong.

PATIENTS

Inpatients aged 12 years or older first diagnosed with carditis were selected as case patients. All other hospitalized patients without carditis were treated as control participants. Ten control participants were randomly matched with each case patient by age, sex, and admission date.

INTERVENTION

Vaccination with BNT162b2 or CoronaVac.

MEASUREMENTS

Incident diagnosis of carditis based on the International Classification of Diseases, Ninth Revision, and elevated troponin levels.

RESULTS

A total of 160 case patients and 1533 control participants were included. Incidence of carditis per 100 000 doses of CoronaVac and BNT162b2 administered was estimated to be 0.31 (95% CI, 0.13 to 0.66) and 0.57 (CI, 0.36 to 0.90), respectively. Multivariable analyses showed that recipients of the BNT162b2 vaccine had higher odds of carditis (adjusted odds ratio [OR], 3.57 [CI, 1.93 to 6.60]) than unvaccinated persons. Stratified by sex, the OR was 4.68 (CI, 2.25 to 9.71) for males and 2.22 (CI, 0.57 to 8.69) for females receiving the BNT162b2 vaccine. The ORs for adults and adolescents receiving the BNT162b2 vaccine were 2.41 (CI, 1.18 to 4.90) and 13.79 (CI, 2.86 to 110.38), respectively. Subanalysis showed an OR of 9.29 (CI, 3.94 to 21.91) for myocarditis and 1.06 (CI, 0.35 to 3.22) for pericarditis associated with BNT162b2. The risk was mainly seen after the second dose of BNT162b2 rather than the first. No association between CoronaVac and carditis with a magnitude similar to that for BNT162b2 was seen.

LIMITATION

Limited sample size, absence of electrocardiography and other clinical investigative data, and unrecorded overseas vaccination exposure.

CONCLUSION

Despite a low absolute risk, there is an increased risk for carditis associated with BNT162b2 vaccination. This elevated risk should be weighed against the benefits of vaccination.

PRIMARY FUNDING SOURCE

Health and Medical Research Fund.

Case Report: Abnormal ECG in a Patient With Acute Pancreatitis

Background: Both acute pancreatitis and acute myocardial infarction (AMI) are rapidly progressive and frequently fatal diseases that can be interrelated and lead to a vicious cycle for further problems. The concomitant occurrence of AMI and acute pancreatitis is rare but critical, and efficient diagnosis and treatment of such patients are challenging.

Case Summary: We reported an uncommon case of abnormal ECG findings in a 63-year-old woman with acute pancreatitis. The patient exhibited increased biomarkers of myocardial injury, such as creatine kinase-MB (CK-MB) and troponin T, as well as ST segment elevation in inferior leads II, III, and aVF. Both of these have been previously observed in patients with acute abdomen in the absence of ST-segment elevation myocardial infarction (STEMI), including pancreatitis. In addition, lacking complaints of chest pain or tightness was also supportive of this idea. Echocardiography indicated abnormalities in the functioning of the left inferior posterior wall segments and decreased overall systolic function of the left ventricle with a 51% ejection fraction. Eventually, AMI was diagnosed after coronary computed tomography angiography (CCTA) showing critical stenosis of the right coronary artery and left anterior descending artery segments. The patient was urgently transferred to intensive care unit and was treated with anticoagulation, antiplatelet aggregation, lipid-lowering and other palliative drugs.

Conclusion: Concomitant acute pancreatitis and AMI are often considered to be critical conditions with a poor prognosis. Therefore, it is important to rapidly identify this condition and consider transferring patients for multidisciplinary supportive care.

Autoimmune and Autoinflammatory Pericarditis: Definitions and New Treatments

PURPOSE OF THE REVIEW

The purpose of the review is to analyze the pathogenetic mechanisms that underlie acute pericarditis, with attention to autoimmune and autoinflammatory pericarditis, and, in addition, to review the available therapeutic armamentarium.

RECENT FINDINGS

Several studies have been published on the use of anti-IL-1 drugs in recurrent pericarditis, including anakinra and rilonacept. The latest, the RHAPSODY study, based on the use of rilonacept in recurrent pericarditis, has recently reached phase 3 with promising results in terms of efficacy and safety. Alterations in the function of the inflammasome and the consequent overproduction of IL-1 play a pivotal role in the genesis of autoinflammatory pericarditis. Recent studies added evidence to the importance of anti-IL-1 drugs in the treatment of recurrent pericarditis with raised C-reactive protein. In the era of tailored medicine, anti-IL-1 agents may be very useful in the subset of patients with recurrent pericarditis and a clear inflammatory phenotype.

Investigating the Usefulness of European Society of Cardiology Guidelines for Hospitalization in Acute Pericarditis at a Single Tertiary Center

Background The European Society of Cardiology (ESC) guidelines for the diagnosis and management of pericardial diseases identify predictive factors of poor prognosis and advise either in favor or against hospitalization accordingly. We aim to evaluate the adequacy of hospitalization criteria in a cohort of patients presenting to the emergency department (ED) with acute pericarditis. Methods Retrospective analysis of patients admitted to ED with acute pericarditis, from 2009 to 2019. During ED stay, all patients were evaluated by a cardiologist who decided if the patient was to be discharged or hospitalized. Hospitalized and discharged patients were compared regarding the primary outcome, defined by a composite of: the need for pericardiocentesis and/or cardiac surgery, pericarditis recurrence, and all-cause death. The clinical decision was then counterpoised with ESC guidelines. Results A total of 192 patients were included in the analysis (median age 44.5 years old, 83.3% male) of which 87 (45.5%) were hospitalized. A total of 25% registered the primary outcome, mainly due to acute pericarditis recurrence, occurring in 21.9%. Predictors of recurrence were: glucocorticoid therapy (Odds Ratio [OR]=11.93, 95% Confidence Inirtval [CI] 3.13-45.5, p<0.001), fever at admission (OR=2.67, 95% CI 1.29-5.49, p=0.008), immunosuppression (OR=4.03, 95% CI 1.280-12.659, p=0.017) and increased cardiothoracic index (OR 3.85, CI 95% 1.67-8.86, p=0.002). Regarding hospitalisation/discharge decision, the ESC guidelines were respected in 73.4% of the cases. However, no significant difference in the primary outcome was noted whether the ESC guidelines were respected or not (27.5% vs. 24.3%, p=0.707). Conclusions Discrepancy between current guidelines and the clinical decision did not translate into a different outcome.

Role of Cardiac Macrophages on Cardiac Inflammation, Fibrosis and Tissue Repair

The immune system plays a pivotal role in the initiation, development and resolution of inflammation following insult or damage to organs. The heart is a vital organ which supplies nutrients and oxygen to all parts of the body. Heart failure (HF) has been conventionally described as a disease associated with cardiac tissue damage caused by systemic inflammation, arrhythmia and conduction defects. Cardiac inflammation and subsequent tissue damage is orchestrated by the infiltration and activation of various immune cells including neutrophils, monocytes, macrophages, eosinophils, mast cells, natural killer cells, and T and B cells into the myocardium. After tissue injury, monocytes and tissue-resident macrophages undergo marked phenotypic and functional changes, and function as key regulators of tissue repair, regeneration and fibrosis. Disturbance in resident macrophage functions such as uncontrolled production of inflammatory cytokines, growth factors and inefficient generation of an anti-inflammatory response or unsuccessful communication between macrophages and epithelial and endothelial cells and fibroblasts can lead to aberrant repair, persistent injury, and HF. Therefore, in this review, we discuss the role of cardiac macrophages on cardiac inflammation, tissue repair, regeneration and fibrosis.

Spodick’s Sign: A Case Report and Review of Literature

Acute pericarditis is commonly diagnosed in patients who present with chest pain. Accurate diagnosis of acute pericarditis is essential because of its relative similarity to ST-elevation myocardial infarction (STEMI) in both clinical presentation and electrocardiogram (EKG) changes. Additionally, troponin elevation is occasionally seen in acute pericarditis due to myocardial involvement (myopericarditis), which makes accurate diagnosis more challenging. A 12-lead EKG remains the most useful diagnostic test in differentiating acute pericarditis from STEMI. Spodick's sign is a less recognized electrocardiographic feature of acute pericarditis and is frequently overlooked by clinicians. We present a case of a 52-year-old male who initially presented with acute onset substernal chest pain. His EKG revealed diffuse subtle ST elevation and downsloping TP segment (Spodick's sign). A coronary angiogram demonstrated normal coronaries which eliminated the possibility of coronary artery disease. In this article, we will discuss how to differentiate between acute pericarditis and myocardial infarction, with a focus on Spodick's sign, amongst other EKG findings suggestive of pericarditis.

Correlation study between ADA and IFN-γ gene polymorphisms and the risk of developing tuberculous pericarditis

OBJECTIVE

To study the correlation between adenosine deaminase (ADA) and IFN-γ gene polymorphism and the risk of tuberculous pericarditis (TBP).

METHODS

Two-hundred and forty-five patients with TBP were enrolled as a study group, including 140 males and 105 females. According to the general information of TBP patients in the study group, 115 patients with non-tuberculous pericarditis were recruited as the control group. Four ADA single nucleotide polymorphisms (SNPs; rs121908715, rs79281338, rs121908723, and rs61737144) and the rs2069707 locus of the IFN-γ polymorphism were detected using PCR and Sanger sequencing.

RESULTS

Carriers with the T allele at the rs121908715 locus of ADA had a higher risk of TBP (adjusted OR = 3.986, 95% CI = 1.858-8.718, p < 0.001). There was a significantly higher risk of TBP in carriers with the G allele at the rs121908723 locus of ADA (adjusted OR = 2.334, 95% CI = 1.084-5.102, p = 0.018). The risk of TBP was higher in carriers with the G allele at the rs2069707 locus of IFN-γ (adjusted OR = 2.844, 95% CI = 1.399-5.853, p = 0.002). TB patients who carry both the T allele at the rs121908715 locus of ADA and the G allele of the IFN-γ gene, or who both carry the G allele at the rs126908723 locus of ADA and the G allele at the rs2069707 locus of IFN-γ have a higher risk of contracting TBP (adjusted OR = 11.034, 95% CI = 2.781-15.328, p < 0.001 and adjusted OR = 10.315, 95% CI = 4.522-13.854, p < 0.001).

CONCLUSION

The ADA SNPs rs12190871 and rs121908723, and the rs2069707 locus SNPs of IFN-γ are risk factors for contracting TBP.

Recurrent pericarditis as an extra-intestinal manifestation of ulcerative colitis in a 14-year-old girl

Pericarditis is a known complication of mesalazine in the treatment of ulcerative colitis. This case study illustrates that after diagnostic work-up, pericarditis should not always be attributed to the use of mesalazine. It may be the presentation of an extra-intestinal manifestation of ulcerative colitis. Restarting of mesalazine should be considered.

Acute Myopericardial Syndromes

Acute myopericardial syndromes are common but can be challenging to manage and potentially have life-threatening complications. Careful clinical history, physical examination, electrocardiogram interpretation, and application of diagnostic criteria are needed to make an accurate diagnosis, exclude concomitant disease, and properly treat patients. Therapy for acute pericarditis should be guided per the underlying cause. For the most common causes, nonsteroidal antiinflammatory drugs or aspirin with the addition of colchicine remains the mainstay of therapy. Patients with hemodynamic compromise who are resistant to therapy or display high-risk features should prompt hospitalization and initiation of more aggressive and/or invasive therapy.

Recurrent pericarditis: a case report and literature review

BACKGROUND

Recurrence affects about 30% (20% to 50%) of patients within 18 months after the initial episode of acute pericarditis resulting in subsequent rehospitalizations. Bearing in mind high treatment costs of patients admitted to hospital with acute and recurrent pericarditis, there is a need to optimize the treatment of both of these conditions.

MATERIALS AND METHODS

We present a case of recurrent pericarditis. The first episode of pericarditis was diagnosed in 2006. Three months later the patient was hospitalized due to clinical symptoms suggesting recurrence of a past condition. Ten years after the initial episode of acute pericarditis the patient was hospitalized for the treatment of recurrent pericarditis. The search for etiology of the disease was unsuccessful, the patient received treatment with nonsteroidal anti-inflammatory drugs; empiric antimicrobial therapy was also administered.

RESULTS AND CONCLUSIONS

Acute pericarditis is the most common disease of the pericardium encountered in clinical practice. Colchicine has been demonstrated as a first-line drug to be added to conventional anti-inflammatory therapies in patients with a first episode of pericarditis or its recurrences in order to improve the response to therapy and reduce recurrences. Despite a large amount of new data, there are still several issues that require additional research and clarification, including the search for new individualized therapies, the best duration of treatment for patients with pericardial diseases, and optimization of patient follow-up in order to collect data on long-term outcomes that would allow shortening the duration of in-patient treatment and reduction of recurrences.