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

Pharmacological preventions and treatments for pericardial complications after open heart surgeries

BACKGROUND

Pericardial complications following cardiac surgery are common and debilitating, significantly impacting patients' survival. We performed this network meta-analysis to identify the most effective and safest preventions and treatments for pericardial complications following cardiac surgery.

METHODS

We systematically searched PubMed/MEDLINE, EMBASE and Cochrane CENTRAL from inception to 22 January 2024. Pairs of reviewers screened eligible studies. They included randomised controlled trials that enrolled adults undergoing major cardiac surgeries and reported postpericardiotomy syndrome, pericardial effusion and pericarditis as primary or secondary outcomes. We summarised the effects of interventions using relative risks and corresponding 95% CIs. We performed a frequentist random-effects network meta-analysis using the restricted maximum likelihood estimator.

RESULTS

We included 39 trials that enrolled a total of 6419 participants. Our network meta-analysis demonstrates colchicine reduces the risk of postpericardiotomy syndrome (RR 0.53, 95% CI 0.38 to 0.73). Beta-blockers probably prevent atrial fibrillation with a large magnitude of effect (RR 0.4, 95% CI 0.20 to 0.81) and may prevent postoperative pericarditis (RR 0.66, 95% CI 0.45 to 0.97) compared with control. Fish oil (RR 0.28, 95% CI 0.09 to 0.90), non-steroidal anti-inflammatory drugs (RR 0.37, 95% CI 0.23 to 0.59) and colchicine (RR 0.37, 95% CI 0.23 to 0.59) may reduce the risk of postoperative atrial fibrillation. We found no evidence of a difference in the risk of pleural effusion, all-cause mortality, serious adverse events or postoperative ICU stay.

CONCLUSIONS

The results of our study highly recommend colchicine use to reduce the risk of the postpericardiotomy syndrome and beta-blocker use to reduce postoperative atrial fibrillation. Additionally, our study suggests that further research is needed to investigate other interventions and to evaluate newly proposed interventions in large, high-quality trials, as the current evidence for some interventions is relatively weak.

Diagnosis, Risk Stratification, and Treatment of Pericarditis: A Review

Importance

Pericarditis accounts for up to 5% of emergency department visits for nonischemic chest pain in North America and Western Europe. With appropriate treatment, 70% to 85% of these patients have a benign course. In acute pericarditis, the development of constrictive pericarditis (<0.5%) and pericardial tamponade (<3%) can be life-threatening.

Observations

Acute pericarditis is diagnosed with presence of 2 or more of the following: sharp, pleuritic chest pain that worsens when supine (≈90%); new widespread electrocardiographic ST-segment elevation and PR depression (≈25%-50%); a new or increased pericardial effusion that is most often small (≈60%); or a pericardial friction rub (<30%). In North America and Western Europe, the most common causes of acute pericarditis are idiopathic or viral, followed by pericarditis after cardiac procedures or operations. Tuberculosis is the most common cause in endemic areas and is treated with antituberculosis therapy, with corticosteroids considered for associated constrictive pericarditis. Treatment of acute idiopathic and pericarditis after cardiac procedures or operations involves use of high-dose nonsteroidal anti-inflammatory drugs (NSAIDs), with doses tapered once chest pain has resolved and C-reactive protein level has normalized, typically over several weeks. These patients should receive a 3-month course of colchicine to relieve symptoms and reduce the risk of recurrence (37.5% vs 16.7%; absolute risk reduction, 20.8%). With a first recurrence of pericarditis, colchicine should be continued for at least 6 months. Corticosteroids are often used if pericarditis does not improve with NSAIDs and colchicine. In certain patients with multiple recurrences, which can occur for several years, interleukin 1 (IL-1) blockers have demonstrated efficacy and may be preferred to corticosteroids.

Conclusions

Acute pericarditis is a common cause of nonischemic chest pain. Tuberculosis is the leading cause of pericarditis in endemic areas and is treated with antitubercular therapy. In North America and Western Europe, pericarditis is typically idiopathic, develops after a viral infection, or develops following cardiac procedures or surgery. Treatment with NSAIDs and colchicine leads to a favorable prognosis in most patients, although 15% to 30% of patients develop recurrence. Patients with multiple recurrent pericarditis can have a disease duration of several years or more, are often treated with corticosteroids, and IL-1 blockers may be used for selected patients as steroid-sparing therapy.

Age-stratified patterns in clinical presentation, treatment and outcomes in acute pericarditis: a retrospective cohort study

BACKGROUND

There are limited data on acute pericarditis according to different age groups. The aim of this study is to investigate the role of age-related features in clinical characteristics, management, and outcomes of acute pericarditis, with a focus on the geriatric population.

METHODS

Patients with a first episode of acute pericarditis were consecutively enrolled between January 2014 and June 2022, and divided into four groups according to age (G1: 18-35 years; G2: 35-55 years; G3: 55-75 years; G4: >75 years). Clinical characteristics and medical therapy were recorded at baseline, and during follow-up.

RESULTS

A total of 471 patients (median age 56.3 (IQR 33-73) years, 32.3% women) were included. Younger age (G1-G2-G3) was associated with a higher frequency of chest pain, pericardial rubs (p<0001), ECG changes (p=0.002) and were more commonly treated with colchicine (p<0.001), and non-steroidal anti-inflammatory drugs (p=0.006). Older patients (G4) depicted more commonly dyspnoea, pericardial/pleural effusion (p=0.007) and were more often treated with corticosteroids (p=0.037). A secondary cause of pericarditis was detected in 128/471 (27.2%) patients. Older patients were more commonly hospitalised and had a complicated course with new-onset atrial fibrillation (p<0.001) and cardiac tamponade (p=0.005), compared with younger patients, who presented more recurrences (respectively G1: 43.0%, G2: 34.7%, G3: 28.2% and G4: 16.2%; p<0.001). After multivariable analysis, younger age remained the strongest independent predictor for recurrences (HR 3.23, 95% CI 1.81 to 5.58, p<0.001).

CONCLUSION

Older age is associated with less recurrences of pericarditis, but more severe complications with need for hospitalisation.

Atrial arrhythmias and acute pericarditis triggered by bleach ingestion-associated oesophageal perforation: a case report

Background

Acute pericarditis due to oesophageal perforation and caustic injury is a rare presentation of bleach ingestion. Cardiac arrhythmias such as atrial fibrillation and atrial flutter have been associated with certain aetiologies of acute pericarditis. This case report presents a unique occurrence of acute pericarditis following bleach ingestion and intermittent atrial fibrillation and atrial flutter triggered by liquid intake.

Case summary

A 36-year-old male with no significant past medical history presented after attempted suicide by ingesting bleach. He had acute pericarditis resulting from caustic oesophageal perforation and extensive mediastinal injury. In the following days, he developed recurrent episodes of atrial fibrillation and atrial flutter following fluid intake, prompting treatment with metoprolol. On Day 5 of hospitalization, he underwent an oesophagogram and developed persistent atrial arrhythmia with haemodynamic instability requiring cardioversion. He underwent thoracoscopic surgery to address the oesophageal injury. A jejunostomy tube was placed and he had complete resolution of his recurrent atrial arrhythmia.

Discussion

This case highlights a rare presentation of atrial arrhythmias and acute pericarditis caused by corrosive oesophageal injury due to bleach ingestion. The effective management of such cases necessitates a co-ordinated approach, involving the collaboration of cardiothoracic surgeons, cardiologists, and critical care specialists, with the aim of enhancing patient outcomes and mitigating the life-threatening risks associated with oesophageal perforation and cardiac arrhythmias. Furthermore, this case underscores the imperative for further research to better understand the relationship between traumatic acute pericarditis and atrial arrhythmias, offering the potential for improved patient care in these intricate clinical scenarios.

Towards Improved Human In Vitro Models for Cardiac Arrhythmia: Disease Mechanisms, Treatment, and Models of Atrial Fibrillation

Heart rhythm disorders, arrhythmias, place a huge economic burden on society and have a large impact on the quality of life of a vast number of people. Arrhythmias can have genetic causes but primarily arise from heart tissue remodeling during aging or heart disease. As current therapies do not address the causes of arrhythmias but only manage the symptoms, it is of paramount importance to generate innovative test models and platforms for gaining knowledge about the underlying disease mechanisms which are compatible with drug screening. In this review, we outline the most important features of atrial fibrillation (AFib), the most common cardiac arrhythmia. We will discuss the epidemiology, risk factors, underlying causes, and present therapies of AFib, as well as the shortcomings and opportunities of current models for cardiac arrhythmia, including animal models, in silico and in vitro models utilizing human pluripotent stem cell (hPSC)-derived cardiomyocytes.

Cardiac Tamponade Risk Associated With Anticoagulation for Atrial Fibrillation in Dialysis-Associated Pericarditis: A Case Report

Heparin is a preferred initial anticoagulant in patients with new-onset atrial fibrillation (AF). Despite continuous debate about the risk, there has been a concern about heparin-induced hemorrhagic pericarditis and cardiac tamponade. We present a case of a new onset atrial fibrillation (AF) in a patient with renal impairment and evidence of pericardial effusion complicated by hemopericardium development after starting anticoagulation. Although the risk of hemorrhagic conversion of uremic pericarditis induced by heparin in ESRD patients with new onset AF was suggested in the literature, this case raises the possibility of a similar complication in dialysis-associated pericarditis. Therefore, we aim to heighten alertness regarding this potential complication of a commonly used medication in clinical practice. We also aim to review the current anticoagulation recommendations in this setting.

Inflammatory signalling in atrial cardiomyocytes: a novel unifying principle in atrial fibrillation pathophysiology

Inflammation has been implicated in atrial fibrillation (AF), a very common and clinically significant cardiac rhythm disturbance, but its precise role remains poorly understood. Work performed over the past 5 years suggests that atrial cardiomyocytes have inflammatory signalling machinery - in particular, components of the NLRP3 (NACHT-, LRR- and pyrin domain-containing 3) inflammasome - that is activated in animal models and patients with AF. Furthermore, work in animal models suggests that NLRP3 inflammasome activation in atrial cardiomyocytes might be a sufficient and necessary condition for AF occurrence. In this Review, we evaluate the evidence for the role and pathophysiological significance of cardiomyocyte NLRP3 signalling in AF. We first summarize the evidence for a role of inflammation in AF and review the biochemical properties of the NLRP3 inflammasome, as defined primarily in studies of classic inflammation. We then briefly consider the broader evidence for a role of inflammatory signalling in heart disease, particularly conditions that predispose individuals to develop AF. We provide a detailed discussion of the available information about atrial cardiomyocyte NLRP3 inflammasome signalling in AF and related conditions and evaluate the possibility that similar signalling might be important in non-myocyte cardiac cells. We then review the evidence on the role of active resolution of inflammation and its potential importance in suppressing AF-related inflammatory signalling. Finally, we consider the therapeutic potential and broader implications of this new knowledge and highlight crucial questions to be addressed in future research.

Tamponnade cardiaque

La tamponnade cardiaque est une urgence vitale. Elle se définit comme une accumulation de liquide dans l’espace intrapéricardique, favorisant une augmentation de la pression intrapéricardique et une altération du remplissage cardiaque. Il s’agit d’une des causes du choc obstructif, et la rapidité d’installation détermine le degré d’instabilité hémodynamique. La morbidité et la mortalité dépendent de la rapidité du diagnostic et de sa prise en charge. Peu fréquemment, l’étiologie est tumorale. Ce type d’étiologie se traduit le plus souvent par des tableaux cliniques d’installation lente et progressive. C’est le cas du sujet qui est présenté dans cet article : un homme de 50 ans sans suivi médical et consommateur d’alcool et de tabac, vivant dans un contexte social difficile. L’issue fatale du cas clinique témoigne de la gravité du tableau de présentation initiale. L’électrocardiogramme peut révéler des signes caractéristiques comme le microvoltage du QRS et l’alternance électrique. La méthode standard pour détecter un épanchement péricardique est l’échocardiographie : le diagnostic de tamponnade cardiaque requiert la présence de collapsus complet du coeur droit et dans les cas plus graves des cavités gauches. Les compétences de l’urgentiste en termes d’échographie permettent un diagnostic plus rapide et précis. Le traitement de la tamponnade cardiaque repose principalement sur le soutien hémodynamique (administration volumique et traitement des éventuels troubles du rythme secondaires) en urgence. Cependant, le traitement définitif reste le drainage du liquide accumulé par péricardiocentèse ou par approche chirurgicale.

Acute Pericarditis: Update

Purpose of Review

Since 2015, when ESC guidelines for the diagnosis and management of pericardial diseases were published, ongoing research has enhanced the current state of knowledge on acute pericarditis. This review is an update on the latest developments in this field.

Recent Findings

In recurrent acute pericarditis, autoinflammation has been included among causative mechanisms restricting the vague diagnoses of “idiopathic” pericarditis. Cardiac magnetic resonance that detects ongoing pericardial inflammation may guide treatment in difficult-to-treat patients. Development of risk scores may assist identification of patients at high risk for complicated pericarditis, who should be closely monitored and aggressively treated. Treatment with IL-1 inhibitors has been proven efficacious in recurrent forms with a good safety profile. Finally, acute pericarditis has recently attracted great interest as it has been reported among side effects post COVID-19 vaccination and may also complicate SARS-CoV-2 infection.

Summary

Recent advancements in acute pericarditis have contributed to a better understanding of the disease allowing a tailored to the individual patient approach. However, there are still unsolved questions that require further research.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11886-022-01710-8.

Chronic pericardial effusion: current concepts and emerging trends

INTRODUCTION

Pericardial effusion (PEF) is a common and challenging pericardial syndrome with a variety of clinical manifestations ranging from asymptomatic, incidentally uncovered small PEFs, to life-threatening cardiac tamponade.

AREAS COVERED

: This review focuses on the pathophysiology, epidemiology, etiology, classification, clinical findings, diagnostic work-up, management and outcome of PEFs. Particular emphasis has been given on the most recent evidence concerning the contribution of imaging for the detection, differential diagnosis and evaluation of the hemodynamic impact of PEFs on the diastolic filling of the heart. Moreover, simplified algorithms for PEF triage and management have been included.

EXPERT OPINION

The management of patients with PEFs is mainly based on four parameters namely hemodynamic impact on diastolic function, elevation of inflammatory markers, presence of a specific underlying condition known to be associated with PEF and finally size and duration of the effusion. Novel data have contributed to change our view towards large, asymptomatic, "idiopathic" PEFs and dictated a rather conservative approach in most cases. It is also stressed that there is a compelling need for additional research, which is essential for tailored treatments aiming at the improvement of quality of life and containment of health care costs.

Effects of oral colchicine administration as first-line adjunct therapy in myopericarditis

BACKGROUND

Although current guidelines recommend routine use of oral colchicine as a first-line adjunct therapy to aspirin/nonsteroidal anti-inflammatory drugs (NSAIDs) for acute and recurrent pericarditis, there are insufficient data to recommend routine use of colchicine for the initial management of myopericarditis.

METHODS

The records of 194 patients who were admitted for myopericarditis were investigated retrospectively. Patients receiving oral colchicine (n = 33) as an adjunct to aspirin/NSAIDs comprised the study group and patients who received conventional therapy (n = 31) formed the control group. Plasma C‑reactive protein (CRP) levels, cardiac biomarkers, and several electrocardiographic parameters of atrial activation were evaluated before the start of treatment and at the 6‑month follow-up.

RESULTS

Assessments before and after treatment with regard to cardiac biomarkers and plasma CRP levels showed improvements in both groups (p > 0.05). There were statistically significant improvements in P wave indices including P wave duration, PR interval length, P wave dispersion, P terminal force, and isoelectric interval in the colchicine therapy group compared with the control group (p < 0.01).

CONCLUSION

Routine use of colchicine for the initial management of myopericarditis as a first-line adjunct therapy to aspirin/NSAIDs in patients with myopericarditis has favorable effects on electrocardiographic indices of atrial activation parameters.

A 70-Year-Old Man With Conspicuous Thigh Pain and ST-Segment Elevations

CASE PRESENTATION

A 70-year-old man presented to the ED with sudden onset of left thigh pain followed by transient chest discomfort. His history included cerebrovascular disease, hypertension, and cocaine and methamphetamine use. Physical examination revealed an uncomfortable male subject with a temperature of 37 °C, heart rate of 129 beats/min, BP of 130/65 mm Hg, and 98% oxygen saturation on room air. There was point tenderness in the left lateral thigh without erythema, swelling, or overlying skin changes. His cardiac examination revealed an irregular tachycardia at 129 beats/min and normal first and second heart sounds without murmurs, gallops, or rubs. The remainder of the examination was unremarkable.

Cancer and atrial fibrillation: Epidemiology, mechanisms, and anticoagulation treatment

Cancer patients are at an increased risk of developing atrial fibrillation (AF) and thrombosis. However, the management of anticoagulation in patients with both diseases may be challenging, and data on these patients are lacking. We summarize the current evidence on the incidence and prevalence of cancer in AF and vice versa and provide some practical considerations on the management of oral anticoagulation in specific clinical situations. Low-molecular weight heparins are not approved for thromboprophylaxis in AF, and management of warfarin can be difficult. The use of direct oral anticoagulants may be particularly attractive for their rapid onset/offset action and lower bleeding risk.

A Case of Atrial Flutter Masking Acute Pericarditis

Atrial flutter (AFL) is a macro-reentrant tachycardia that can be provoked by numerous factors, including acute pericarditis. We present a case of new-onset AFL masking acute pericarditis in a man with multiple comorbid conditions, including hypertension, chronic kidney disease, and obstructive sleep apnea. After a failed attempt of rate control, the patient underwent successful cardioversion, which revealed electrocardiographic findings consistent with acute pericarditis. Colchicine was avoided in the setting of chronic kidney disease and the patient was treated with a steroid taper. Pericarditis is a rare cause of AFL, and this case demonstrates the diagnostic and management considerations for AFL and acute pericarditis.

Recurrent pericarditis: an update on diagnosis and management

Acute pericarditis is a disease of the pericardium characterized by inflammation. Around 16-38% of patients develop recurrent events after the first episode. Recurrent pericarditis (RP) seems to be caused by a pathologic immune response. An inadequate treatment in terms of drug choice, dose, duration of therapy or tapering, has been shown to increase the risk of recurrences. Symptoms, physical signs and electrocardiographic signs are usually less severe during a recurrent event as compared to the first episode, thus favoring imaging as a tool to confirm the diagnosis of RP. Cardiac magnetic resonance is becoming the technique of choice because of its ability to detect active pericardial inflammation. Inflammatory biomarkers can be used to assess the risk of recurrences and to guide the tapering of treatments. First-line treatment is based on non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine. NSAIDs are useful for pain control, and colchicine has shown to reduce the risk of further recurrences. Glucocorticoids are often used as second-line drugs, but they are associated with a high rate of recurrent events. Interleukin-1 inhibitors, such as anakinra and rilonacept, significantly reduce the risk of recurrences in patients with RP while on treatment.

Contemporary management of pericardial effusion

Pericardial effusion is a relatively common clinical condition with a variety of clinical manifestations ranging from incidentally discovered asymptomatic cases to life-threatening cardiac tamponade. The etiology encompasses idiopathic cases and forms secondary to different conditions, including autoimmune diseases, malignancies, metabolic disorders, etc. While medical therapy should be offered to patients with elevation of inflammatory markers, in specific forms treatment should be appropriate to the underlying disorder. In cases with hemodynamic compromise pericardial drainage either with pericardiocentesis or pericardial "window" is indicated for therapeutic and diagnostic purposes. In the remainder, factors like comorbidities, size and location of the pericardial effusion will influence the clinical decision making. In asymptomatic or minimally symptomatic chronic large idiopathic pericardial effusions, according to recent evidence, a conservative approach with watchful waiting seems the most reasonable option. The prognosis of pericardial effusions largely depends on the underlying etiologies. Metastatic spread to the pericardium has an ominous prognosis whereas large to moderate effusions have been often associated with known or newly discovered specific underlying causes. Chronic small idiopathic effusions have an excellent prognosis and do not require specific monitoring. Large chronic idiopathic effusions in clinically stable patients require a 3 to 6-month assessment ideally in a specialized unit.

[CME-ECG 70: Chest Pain in a Young Patient - Differential Diagnoses beyond the Acute Coronary Syndrome]

CME-ECG 70: Chest Pain in a Young Patient - Differential Diagnoses beyond the Acute Coronary Syndrome Abstract. Older patients with chest pain and typical ECG changes are most likely to be diagnosed with cardiovascular diseases. However, younger patients with similar symptoms may reveal different disease patterns. In this case report, differential diagnoses and diagnostic steps, with particular attention to the ECG, will be discussed.

Catheter ablation of atrial fibrillation after pericardiectomy: multi-center experience in China

Background

To study the effectiveness and safety of atrial fibrillation (AF) catheter ablation after pericardiectomy.

Methods

Data of 24 consecutive AF patients after pericardiectomy underwent catheter ablation from five centers were collected and analyzed retrospectively. All patients were followed up at 1, 3, and 12 months after catheter ablation. Results of a repeated blood test, electrocardiogram, and echocardiography during follow-up were also collected. Adverse events such as recurrence of AF, heart failure, stroke/transient ischemic attack (TIA) and minor, and major bleeding were recorded. All patients underwent brain magnetic resonance imaging (MRI) at the end of 12 months follow-up.

Results

Patients were young (20-73 years old, 48.1±11.0). Fifteen (62.5%) patients were male. CHA2DS2-VASc score (0-3, 0.21±0.41) was low in these 24 patients. Among these patients, 11 (45.8%) were paroxysmal AF, 8 (33.3%) were persistent AF, and 5 (20.8%) were long-lasting persistent AF. Left atrium diameter over 45 mm was detected in 17 (70.8%) patients. All patients underwent catheter ablation successfully. No peri-ablation procedure-related complication happened. Oral anticoagulant therapy was stopped 3 months after the final ablation. Anti-arrhythmia drugs were continued for all patients after ablation. For 12 months follow-up, AF recurred in 10 (41.7%) patients 3-7 months after the first ablation. MRI detected silent cerebral infarction (SCI) in 2 (8.3%) patients. No other adverse events occurred during follow-up.

Conclusions

It is safe for AF patients to undergo catheter ablation after pericardiectomy, but the rate of recurrence of AF is high.

Anti-inflammatory drugs in the prevention of post-operative atrial fibrillation: a literature review

Atrial fibrillation (AF) is a serious and common complication following heart surgery. Cardiac surgery triggers inflammation in the heart and makes it susceptible to the incidence of AF. Therefore, anti-inflammatory drugs may reduce the rate of AF incidence in the post-surgery conditions. Immunosuppressant agents, steroidal anti-inflammatory drugs (corticosteroids), non-aspirin non-steroid anti-inflammatory drugs (NSAIDs), colchicine and omega-3 unsaturated fatty acids (n-3 UFA) are drugs with well-known anti-inflammatory properties. The efficacy, safety and other aspects of using these drugs in the prevention of post-operative AF (POAF) have been reviewed here. Studies evaluating the efficacy of colchicine have shown that it could be effective in the prevention of POAF. However, there is a need for additional studies to find a colchicine regimen with optimal efficacy and higher tolerability. The use of corticosteroids may also be of value based on the most of meta-analyses. In the case of n-3 polyunsaturated fatty acids and NSAIDs, current data fail to support their efficacy in POAF prevention. Moreover, perioperative administration of NSAIDs may be associated with some severe safety considerations. Immunosuppressant agents have not been used for the prevention of POAF. Further studies are needed to find the most effective strategy for POAF prevention with the least safety considerations and the highest health benefits.

Cardiovascular Sonothrombolysis

PURPOSE OF REVIEW

This review will provide recent pre-clinical and initial clinical trials exploring the efficacy of sonothrombolysis as an adjunct to current emergent therapies in acute coronary syndromes.

RECENT FINDINGS

The initial clinical trials examining the efficacy of short pulse duration diagnostic ultrasound (DUS) high mechanical index impulses in patients with ST segment elevation myocardial infarction (STEMI) have demonstrated that there is improved patency of the infarct vessel, and improved microvascular flow following percutaneous coronary intervention. Subsequent randomized prospective trials have confirmed that in patients with acute STEMI receiving an intravenous microbubble infusion, diagnostic high mechanical index impulses applied in the apical windows pre- and post-percutaneous coronary intervention have reduced myocardial infarction size, as assessed by magnetic resonance imaging at 72 h following presentation, and have been associated with better left ventricular systolic function at 6 month follow-up. Sonothrombolysis has potential for improving early epicardial coronary artery patency and reduce left ventricular remodeling when added to current interventional strategies in STEMI.

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.

Effect of colchicine in prevention of pericardial effusion and atrial fibrillation: a meta-analysis

Randomized, controlled trials (RCTs) have assessed the effect of colchicine therapy in prevention of pericardial effusion (PE) and atrial fibrillation (AF). However, the effects are still inconclusive. PubMed, Cochrane Library, Google Scholar, and EMBASE database were searched. Primary outcome was the risk of PE and AF. Ten RCTs with 1981 patients and a mean follow-up of 12.6 months were included. Colchicine therapy was not associated with a significantly lower risk of post-operative PE (RR, 0.89; 95 % CI 0.70-1.13; p = 0.33, I (2) = 72.8 %) and AF (RR, 0.77; 95 % CI 0.52-1.13; p = 0.18, I (2) = 47.3 %). However, rates of pericarditis recurrence, symptoms persistence, and pericarditis-related hospitalization were significantly decreased with colchicine treatment. In addition, cardiac tamponade occurrence was similar between groups, and adverse events were significantly higher in the colchicine group. Colchicine may not significantly decrease the post-operative risk of PE and AF. However, only limited studies about patients undergoing cardiac surgery provide data about PE and AF.

Atrial Fibrillation Associated Genetic Variants and Left Atrial Histology: Evaluation for Molecular Sub-Phenotypes

INTRODUCTION

Genome wide association studies have identified several single nucleotide polymorphisms (SNPs) associated with atrial fibrillation (AF), but the mechanisms underlying these relationships have not yet been elucidated. Inflammation and fibrosis have been posited as important mechanisms responsible for AF. We sought to investigate the impact of SNP carrier status on inflammation and fibrosis in left atrial appendage tissue.

METHODS AND RESULTS

Carrier status of 10 AF-associated SNPs was evaluated on DNA extracted from left atrial appendage tissue in 176 individuals (120 with AF). The presence of inflammation was evaluated through visual quantification of leukocyte infiltration following hematoxylin and eosin staining, while fibrosis was quantified using picrosirius red with fast green staining. Unadjusted and adjusted linear and logistic regression models were utilized to evaluate for an association between SNP carrier status and inflammation and fibrosis. On adjusted logistic regression analysis, the rs7164883 SNP (intronic within HCN4) was associated with a reduced odds of inflammation (odds ratio: 0.42; 95% CI: 0.22-0.81, P = 0.01), and was not associated with fibrosis on adjusted linear regression analysis (β-coefficient: -0.31; 95% CI: -1.03-0.40, P = 0.40). None of the remaining SNPs exhibited significant associations with left atrial inflammation or fibrosis.

CONCLUSIONS

Among 10 AF-associated SNPs, a single genetic variant was associated with reduced left atrial inflammation, while no histologic differences were observed in the remaining 9. The known AF-associated SNPs do not appear to predispose to the development of pro-inflammatory or pro-fibrotic AF sub-phenotypes.

Utilization of diagnostic ultrasound and intravenous lipid-encapsulated perfluorocarbons in non-invasive targeted cardiovascular therapeutics

Diagnostic ultrasound (DUS) pressures have the ability to induce inertial cavitation (IC) of systemically administered microbubbles; this bioeffect has many diagnostic and therapeutic implications in cardiovascular care. Diagnostically, commercially available lipid-encapsulated perfluorocarbons (LEP) can be utilized to improve endocardial and vascular border delineation as well as assess myocardial perfusion. Therapeutically, the liquid jets induced by IC can alter endothelial function and dissolve thrombi within the immediate vicinity of the cavitating microbubbles. The cavitating LEP can also result in the localized release of any bound therapeutic substance at the site of insonation. DUS-induced IC has been tested in pre-clinical studies to determine what effect it has on acute vascular and microvascular thrombosis as well as nitric oxide (NO) release. These pre-clinical studies have consistently shown that DUS-induced IC of LEP is effective in restoring coronary vascular and microvascular flow in acute ST segment elevation myocardial infarction (STEMI), with microvascular flow improving even if upstream large vessel flow has not been achieved. The initial clinical trials examining the efficacy of short pulse duration DUS high mechanical index impulses in patients with STEMI are underway, and preliminary studies have suggested that earlier epicardial vessel recanalization can be achieved prior to arriving in the cardiac catheterization laboratory. DUS high mechanical index impulses have also been effective in pre-clinical studies for targeting DNA delivery that has restored islet cell function in type I diabetes and restored vascular flow in the extremities downstream from a peripheral vascular occlusion. Improvements in this technique will come from three dimensional arrays for therapeutic applications, more automated delivery techniques that can be applied in the field, and use of submicron-sized acoustically activated LEP droplets that may better permeate the clot prior to DUS activation and cavitation. This article will focus on these newer developments for DUS therapeutic applications.

Almanac 2015: atrial fibrillation research in Heart

Atrial fibrillation continues to attract interest in the cardiovascular community and in Heart. Over 60 original research and review papers published in Heart in 2014–2015 cover various aspects of atrial fibrillation, from associated conditions and precipitating factors to new approaches to management. Here, we provide an overview of articles on atrial fibrillation published in Heart in 2014–2015, highlighting new developments, emerging concepts and novel approaches to treatment.