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Kole C, Stefanou Ε, Karvelas N, Schizas D, Toutouzas KP. Acute and Post-Acute COVID-19 Cardiovascular Complications: A Comprehensive Review. Cardiovasc Drugs Ther 2024; 38:1017-1032. [PMID: 37209261 PMCID: PMC10199303 DOI: 10.1007/s10557-023-07465-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE OF REVIEW The risk of cardiovascular complications due to SARS-CoV-2 are significantly increased within the first 6 months of the infection. Patients with COVID-19 have an increased risk of death, and there is evidence that many may experience a wide range of post-acute cardiovascular complications. Our work aims to provide an update on current clinical aspects of diagnosis and treatment of cardiovascular manifestations during acute and long-term COVID-19. RECENT FINDINGS SARS-CoV-2 has been shown to be associated with increased incidence of cardiovascular complications such as myocardial injury, heart failure, and dysrhythmias, as well as coagulation abnormalities not only during the acute phase but also beyond the first 30 days of the infection, associated with high mortality and poor outcomes. Cardiovascular complications during long-COVID-19 were found regardless of comorbidities such as age, hypertension, and diabetes; nevertheless, these populations remain at high risk for the worst outcomes during post-acute COVID-19. Emphasis should be given to the management of these patients. Treatment with low-dose oral propranolol, a beta blocker, for heart rate management may be considered, since it was found to significantly attenuate tachycardia and improve symptoms in postural tachycardia syndrome, while for patients on ACE inhibitors or angiotensin-receptor blockers (ARBs), under no circumstances should these medications be withdrawn. In addition, in patients at high risk after hospitalization due to COVID-19, thromboprophylaxis with rivaroxaban 10 mg/day for 35 days improved clinical outcomes compared with no extended thromboprophylaxis. In this work we provide a comprehensive review on acute and post-acute COVID-19 cardiovascular complications, symptomatology, and pathophysiology mechanisms. We also discuss therapeutic strategies for these patients during acute and long-term care and highlight populations at risk. Our findings suggest that older patients with risk factors such as hypertension, diabetes, and medical history of vascular disease have worse outcomes during acute SARS-CoV-2 infection and are more likely to develop cardiovascular complications during long-COVID-19.
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Affiliation(s)
- Christo Kole
- Cardiology Department, Sismanoglio General Hospital of Attica, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Εleni Stefanou
- Artificial Kidney Unit, General Hospital of Messinia, Kalamata, Greece
| | - Nikolaos Karvelas
- Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Sanaka H, Haroun E, Arockiam AD, Dong T, Klein A, Wang TKM. Advances in the Multimodality Imaging and Management of Recurrent Pericarditis: A Contemporary Review. Curr Cardiol Rep 2024:10.1007/s11886-024-02133-3. [PMID: 39302591 DOI: 10.1007/s11886-024-02133-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2024] [Indexed: 09/22/2024]
Abstract
PURPOSE OF REVIEW To outline recent advances in imaging and treatment for recurrent pericarditis (RP). RECENT FINDINGS Greater understanding of NLRP3 inflammasome activation in the pathogenesis of RP has led to the development of several anti-interleukin (IL-1) agents, and technological advancements have increased the utility of multimodality imaging in RP. Multimodality imaging plays a crucial role in the assessment of RP, with echocardiography serving as the initial imaging modality; cardiac magnetic resonance (CMR) as a pivotal test for diagnosis, grading severity, and surveillance; and cardiac computed tomography (CT) providing complimentary information and assisting operative assessment. Anti-IL-1 agents are now well-established as second line therapy for RP, with recent clinical trials demonstrating their efficacy.
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Affiliation(s)
- Harsha Sanaka
- Biomedical Science Undergraduate Program, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Elio Haroun
- Pericardial Diseases Center, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Aro Daniela Arockiam
- Pericardial Diseases Center, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Tiffany Dong
- Pericardial Diseases Center, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Allan Klein
- Pericardial Diseases Center, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Tom Kai Ming Wang
- Pericardial Diseases Center, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
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Dong T, Klein AL, Wang TKM. Paradigm Shift in Diagnosis and Targeted Therapy in Recurrent Pericarditis. Curr Cardiol Rep 2023; 25:993-1000. [PMID: 37458866 DOI: 10.1007/s11886-023-01912-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE OF THE REVIEW We review the pathophysiology, diagnosis, and contemporary treatment for recurrent pericarditis, with focus on interleukin-1 (IL-1) inhibitors. RECENT FINDINGS Recurrent pericarditis occurs in about 15-30% of patients who have acute pericarditis. With increased understanding of the autoinflammatory pathophysiology of recurrent pericarditis, IL-1 inhibitors including anakinra, canakinumab, and rilonacept have been applied to this condition with great promise. In particular, the RHAPSODY trial found rilonacept significantly improves pain and inflammation, while also reducing recurrence with few adverse events. The next IL-1 inhibitor on the block for pericarditis, goflikicept, is also discussed. Understanding the role of the inflammasome via the autoinflammatory pathway in pericarditis has led to incorporation of IL-1 inhibitors in the treatment of recurrent pericarditis, with proven efficacy and safety and randomized trials. This will lead to increase uptake of this agent which demonstrated lower rates of recurrence and faster time to resolution.
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Affiliation(s)
- Tiffany Dong
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Tom Kai Ming Wang
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland Clinic Main Campus, Cleveland, OH, USA.
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Avondo S, Andreis A, Casula M, Biondi-Zoccai G, Imazio M. Pharmacologic treatment of acute and recurrent pericarditis: a systematic review and meta-analysis of controlled clinical trials. Panminerva Med 2021; 63:314-323. [PMID: 34738773 DOI: 10.23736/s0031-0808.21.04263-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Recurrence is the most frequent complication following acute pericarditis and may occur in 30% patients, rising to 50% in case of multiple recurrences, lack of colchicine treatment or use of glucocorticoids. Available treatments include aspirin or non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, glucocorticoids, immunosuppressive agents, immunoglobulins, anti-interleukin-1 (IL-1) agents. EVIDENCE ACQUISITION This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to assess the efficacy of pharmacological treatments for acute and recurrent pericarditis. Bibliographic databases were searched (PubMed, MEDLINE, Embase, Scopus, and the Cochrane Library) using the terms "acute pericarditis" or "recurrent pericarditis" and "colchicine" or "NSAIDs" or "glucocorticoids" or "immunosuppressive agents" or "immunoglobulins" or "anti-IL1 agents." Random-effects meta-analysis was used to assess the risk of recurrent pericarditis. Publication bias was assessed using the Egger test, and meta-regression was performed to assess sources of heterogeneity. EVIDENCE SYNTHESIS Eleven RCTs assessed the efficacy of pharmacological treatments for acute and recurrent pericarditis (colchicine and anti-interleukin-1 agents). Colchicine, assessed in nine RCTs, was effective in the reduction of recurrent pericarditis, compared with standard treatment (17% vs .34%, RR=0.50; 95% CI 0.42-0.60, P<0.001), without any differences according to clinical setting (i.e. acute pericarditis, recurrent pericarditis, post-pericardiotomy syndrome; P=0.58). Anti-interleukin-1 agents (anakinra, rilonacept), assessed in two RCT, were effective in the reduction of recurrences, compared with placebo (10% vs.78%, RR=0.14; 95% CI 0.05-0.35, P<0.001). CONCLUSIONS A correct pharmacological management of pericarditis is key to prevent recurrences. Colchicine is the mainstay of treatment in acute and recurrent pericarditis, while anti-IL1 agents are a valuable option in case of recurrent pericarditis refractory to conventional drugs.
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Affiliation(s)
- Stefano Avondo
- Department of Cardiology, Città della Salute e della Scienza, Turin, Italy
| | - Alessandro Andreis
- Department of Cardiology, Città della Salute e della Scienza, Turin, Italy
| | - Matteo Casula
- Department of Cardiology, Città della Salute e della Scienza, Turin, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Massimo Imazio
- Department of Cardiology, Città della Salute e della Scienza, Turin, Italy - .,Unit of Cardiology, Cardiothoracic Department, University Hospital "Santa Maria della Misericordia", Udine, Italy
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The Impact of Physical Activity on Pericarditis. Curr Cardiol Rep 2021; 23:150. [PMID: 34448954 PMCID: PMC8390544 DOI: 10.1007/s11886-021-01578-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2021] [Indexed: 12/02/2022]
Abstract
Purpose of Review To discuss the possible harmful effects and pathophysiology of exercise in cases of pericarditis, explore the role of multi-modality imaging to help guide exercise recommendations, and compare U.S. with European guideline recommendations on the safe resumption of physical activity following resolution of pericarditis. Recent Findings Despite multiple postulated mechanisms by which exercise may be harmful during active inflammation of the myocardium or pericardium, the exact pathophysiology remains largely unknown. The inclusion of multi-modality cardiac imaging may play a role in further elucidating the relationship of exercise with outcomes in pericarditis. More recently, the prevalence of COVID-19 cardiac involvement in athletes prior to returning to play appears lower than previously reported; however, current recommendations are consistent with those for other etiologies of pericarditis. Summary Further research is certainly needed to better understand the relationship between physical activity and pericarditis, the pathophysiology, and the prognostic role of multimodality imaging.
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Yılmaz F, Yılmaz FK, Karagöz A, Yıldırım A, Gunes HM, Akbas RB, Efe SÇ, Barutçu İ. Usefulness of neutrophil-to-lymphocyte ratio for predicting acute pericarditis outcomes. Acta Cardiol 2021; 77:422-430. [PMID: 34275415 DOI: 10.1080/00015385.2021.1951998] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In daily practice, C-reactive protein (CRP) may be used to predict recurrence and treatment response in patients with acute pericarditis; however, the predictive role of CRP might be insufficient for clinical prediction in some patients. In this study, we aimed to investigate the relationship between neutrophil-to-lymphocyte ratio (NLR) and the composite endpoint of pericarditis recurrence and/or tamponade within 1 year in patients with acute pericarditis. METHODS A total of 104 patients diagnosed with acute idiopathic pericarditis (mean age 42.8 ± 15.2 years, 55.8% male) were included in the study. Physical examination findings of these patients, electrocardiography, echocardiography, chest X-ray and laboratory findings were evaluated and analysed. During the 1-year follow-up, the composite of cardiac tamponade and/or pericarditis recurrence was investigated as the primary endpoint of the study. RESULTS Compared to the group without the composite outcome, the group with the composite outcome had significantly higher rates of moderate and severe pericardial effusion (p < 0.01) and higher white blood cell (WBC) count (p:0.001), platelet count (p = 0.003), NLR (2.14 (1.49-3.02) vs 6.60 (5.50-8.68); p < 0.001) and high-sensitivity C-reactive protein (hs-CRP) (8.01 (5.1-24.5 vs 69.5 (40.8-128); p:0.001). Higher hs-CRP (p < 0.001), WBC (p:0.001), NLR (p < 0.001) and platelets (p:0.02) were associated with pericarditis recurrence. NLR and hs-CRP were independently associated with the composite endpoint (p < 0.001 and p < 0.001, respectively). CONCLUSION NLR and hs-CRP were found to be independent predictors for the composite endpoint of tamponade and/or recurrence in acute pericarditis patients during the 1-year follow-up. Similar to hs-CRP, NLR may also be used for risk assessment in patients with idiopathic pericarditis.
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Affiliation(s)
- Fatih Yılmaz
- Kartal Kosuyolu Research and Education Hospital, Kartal, Turkey
| | | | - Ali Karagöz
- Kartal Kosuyolu Research and Education Hospital, Kartal, Turkey
| | - Arzu Yıldırım
- Faculty of Medicine, Cardiology Department, Medipol University, Istanbul, Turkey
| | - Haci Murat Gunes
- Faculty of Medicine, Cardiology Department, Medipol University, Istanbul, Turkey
| | | | | | - İrfan Barutçu
- Faculty of Medicine, Cardiology Department, Medipol University, Istanbul, Turkey
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Duran M, Alsancak Y, Ziyrek M. Effects of oral colchicine administration as first-line adjunct therapy in myopericarditis. Herz 2021; 47:166-174. [PMID: 34114046 DOI: 10.1007/s00059-021-05040-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/30/2021] [Accepted: 04/19/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Mustafa Duran
- Department of Cardiology, Konya Training and Research Hospital, Konya, Turkey
| | - Yakup Alsancak
- Meram Medical Faculty Department of Cardiology Meram/Konya, Necmettin Erbakan University, 042065, Meram/Konya, Turkey.
| | - Murat Ziyrek
- Department of Cardiology, Konya Training and Research Hospital, Konya, Turkey
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Andreis A, Imazio M, de Ferrari GM. Contemporary diagnosis and treatment of recurrent pericarditis. Expert Rev Cardiovasc Ther 2019; 17:817-826. [DOI: 10.1080/14779072.2019.1691916] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Alessandro Andreis
- Cardiovascular and Thoracic Department, University Cardiology, Torino, Italy
- AOU Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Massimo Imazio
- Cardiovascular and Thoracic Department, University Cardiology, Torino, Italy
- AOU Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Gaetano Maria de Ferrari
- Cardiovascular and Thoracic Department, University Cardiology, Torino, Italy
- AOU Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
- Department of Medical Sciences, University of Torino, Torino, Italy
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Vukomanovic V, Prijic S, Krasic S, Borovic R, Ninic S, Nesic D, Bjelakovic B, Popovic S, Stajević M, Petrović G. Does Colchicine Substitute Corticosteroids in Treatment of Idiopathic and Viral Pediatric Pericarditis? MEDICINA-LITHUANIA 2019; 55:medicina55100609. [PMID: 31547038 PMCID: PMC6843123 DOI: 10.3390/medicina55100609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/07/2019] [Accepted: 09/16/2019] [Indexed: 12/12/2022]
Abstract
Background and Objectives: Recurrence of pericarditis (ROP) is an important complication of the acute pericarditis. The aim of this study was to analyse the influence of aetiology, clinical findings and treatment on the outcome of acute pericarditis. Methods: Data were retrospectively collected from medical records of patients treated from 2011 to 2019 at a tertiary referent heart paediatric center. Results: Our investigation included 56 children with idiopathic and viral pericarditis. Relapse was registered in 8/56 patients, 2/29 (7.41%) treated with nonsteroidal anti-inflammatory drugs (NSAID) and 6/27 (28.57%) treated with corticosteroids (CS) and NSAID. Independent risk factors for ROP were viral pericarditis (p = 0.01, OR 31.46), lack of myocardial affection (p = 0.03, OR 29.15), CS use (p = 0.02, OR 29.02) and ESR ≥ 50 mm/h (p = 0.03, OR 25.23). In 4/8 patients the first recurrence was treated with NSAID and colchicine, while treatment of 4/8 patients included CS. Children with ROP treated with CS had higher median number of recurrence (5, IQR: 2–15) than those treated with colchicine (0, IQR: 0–0.75). Conclusions: Independent risk factors for recurrence are CS treatment, viral aetiology, pericarditis only and ESR ≥ 50 mm/h. Acute pericarditis should be treated with NSAID. Colchicine and NSAID might be recommended in children with the first ROP.
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Affiliation(s)
- Vladislav Vukomanovic
- Cardiology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia.
| | - Sergej Prijic
- Cardiology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia.
| | - Stasa Krasic
- Cardiology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
| | - Ruzica Borovic
- Pediatrics Department, Hospital "Sveti Vracevi", 76300 Bijeljina, Bosnia and Herzegovina.
| | - Sanja Ninic
- Cardiology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
| | - Dejan Nesic
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia.
- Institute of Medical Physiology "Rihard Burian", 11000 Belgrade, Serbia.
| | - Bojko Bjelakovic
- Clinic of Pediatrics, Clinical Center Nis, School of Medicine, University of Nis, 18000 Nis, Serbia.
| | - Sasa Popovic
- Cardiology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
| | - Mila Stajević
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia.
- Cardiac Surgery Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
| | - Gordana Petrović
- Immunology Department, Mother and Child Health Care Institute of Serbia "Dr.Vukan Cupic", 11070 Belgrade, Serbia.
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Chahine J, Ala CK, Gentry JL, Pantalone KM, Klein AL. Pericardial diseases in patients with hypothyroidism. Heart 2019; 105:1027-1033. [PMID: 30948517 DOI: 10.1136/heartjnl-2018-314528] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/07/2019] [Accepted: 02/25/2019] [Indexed: 01/08/2023] Open
Abstract
Hypothyroidism is a well-known cause of pericardial effusion (with an incidence of 3%-37%) and can cause cardiac tamponade in severe cases. In this review, we present the current knowledge on the epidemiology of hypothyroid-induced pericardial diseases, the mechanism through which low thyroid hormone levels affect the pericardium, the associated clinical manifestations, diagnostic tests and management options. Hypothyroidism causes pericardial effusion through increased permeability of the epicardial vessels and decreased lymphatic drainage of albumin, resulting in accumulation of fluid in the pericardial space. Interestingly, autoimmunity does not seem to play a major role in the pathophysiology, and a majority of effusions are asymptomatic due to slow fluid accumulation. The diagnosis is generally made when the pericardial disease is associated with an elevated thyroid-stimulating hormone level, and other secondary causes are excluded. Management consists of thyroid replacement therapy, along with pericardial drainage in case of tamponade.In conclusion, hypothyroidism-induced pericardial diseases are underdiagnosed. Initiating treatment early in the disease process and preventing complications relies on early diagnosis through systematic screening per guidelines.
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Affiliation(s)
- Johnny Chahine
- Department of Medicine, Cleveland Clinic, Fairview Hospital, Cleveland, Ohio, USA
| | - Chandra K Ala
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - James L Gentry
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Brucato A, Emmi G, Cantarini L, Di Lenarda A, Gattorno M, Lopalco G, Marcolongo R, Imazio M, Martini A, Prisco D. Management of idiopathic recurrent pericarditis in adults and in children: a role for IL-1 receptor antagonism. Intern Emerg Med 2018; 13:475-489. [PMID: 29633070 DOI: 10.1007/s11739-018-1842-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/21/2018] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Antonio Brucato
- Internal Medicine Division, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Largo Brambilla 3, 50134, Firenze, Italy.
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases, Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, University of Siena, Siena, Italy
| | | | - Marco Gattorno
- Unit of Autoinflammatory Diseases and Immunodeficiencies, Clinic of Pediatrics and Rheumatology, "G. Gaslini" Institute, Genoa, Italy
| | - Giuseppe Lopalco
- Rheumatology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Renzo Marcolongo
- Clinical Immunology, Department of Medicine, Azienda Ospedaliera-Università, Padua, Italy
| | - Massimo Imazio
- AOU Città della Salute e della Scienza di Torino, University Cardiology, Torino, Italy
| | - Alberto Martini
- Unit of Autoinflammatory Diseases and Immunodeficiencies, Clinic of Pediatrics and Rheumatology, "G. Gaslini" Institute, Genoa, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Firenze, Largo Brambilla 3, 50134, Firenze, Italy
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13
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Abstract
Colchicine is an ancient drug with anti-inflammatory effects especially on neutrophils. These cells are critically involved in pericardial and atherosclerotic plaques inflammation, thus representing a new potential target for new therapies to treat and especially prevent cardiovascular events such as pericarditis, atrial fibrillation triggered by inflammation and ischemic vascular events. The aim of the present review is to briefly review the essential pharmacology and explore potential efficacy and safety of colchicine for new emerging cardiovascular indications.
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Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital & Department of Public Health & Pediatrics, University of Torino, Torino, Italy
| | - Fiorenzo Gaita
- University Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Torino, Torino, Italy
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14
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Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristić AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W. 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; 36:2921-2964. [PMID: 26320112 PMCID: PMC7539677 DOI: 10.1093/eurheartj/ehv318] [Citation(s) in RCA: 1405] [Impact Index Per Article: 156.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Yehuda Adler
- Corresponding authors: Yehuda Adler, Management, Sheba Medical Center, Tel Hashomer Hospital, City of Ramat-Gan, 5265601, Israel. Affiliated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel, Tel: +972 03 530 44 67, Fax: +972 03 530 5118,
| | - Philippe Charron
- Corresponding authors: Yehuda Adler, Management, Sheba Medical Center, Tel Hashomer Hospital, City of Ramat-Gan, 5265601, Israel. Affiliated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel, Tel: +972 03 530 44 67, Fax: +972 03 530 5118,
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Imazio M. Idiopathic recurrent pericarditis as an immune-mediated disease: current insights into pathogenesis and emerging treatment options. Expert Rev Clin Immunol 2014; 10:1487-92. [PMID: 25307995 DOI: 10.1586/1744666x.2014.965150] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Idiopathic recurrent pericarditis affects 30-50% of patients with a previous attack of pericarditis. The etiopathogenesis is incompletely understood and most cases remain idiopathic with a presumed immune-mediated pathogenesis. The mainstay of therapy is aspirin or a nonsteroidal anti-inflammatory drug plus colchicine and the possible adjunct of a low-to-moderate dose of a corticosteroid in more difficult cases. Colchicine as an adjunct to anti-inflammatory therapy reduces by 50% the subsequent recurrent rate. For true refractory cases with failure of standard combination therapies, new and emerging options especially include human intravenous immunoglobulins and biological agents (i.e., anakinra). The outcome of idiopathic recurrent pericarditis is good with a negligible risk of developing constrictive pericarditis. Thus, it is important to reassure patients on their prognosis, explaining the nature of the disease and the likely course. Moreover, therapeutic choices should include less toxic agents and favor cheaper drugs whenever possible.
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Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital and University of Torino, Via Luigi Cibrario 72, 10141 Torino, Italy
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Imazio M. Treatment of recurrent pericarditis. ACTA ACUST UNITED AC 2013; 67:345-8. [PMID: 24774725 DOI: 10.1016/j.rec.2013.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 08/13/2013] [Indexed: 11/18/2022]
Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital, Torino, Italy.
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Roubille F, Tournoux F, Roubille C, Merlet N, Davy JM, Rhéaume E, Busseuil D, Tardif JC. Management of pericarditis and myocarditis: could heart-rate-reducing drugs hold a promise? Arch Cardiovasc Dis 2013; 106:672-9. [PMID: 24070595 DOI: 10.1016/j.acvd.2013.06.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 06/18/2013] [Accepted: 06/20/2013] [Indexed: 12/22/2022]
Abstract
Rest is usually recommended in acute pericarditis and acute myocarditis. Given that myocarditis often leads to hospitalization, this task seems easy to carry out in hospital practice; however, it could be a real challenge at home in daily life. Heart rate-lowering treatments (mainly beta-blockers) are usually recommended in case of acute myocarditis, especially in case of heart failure or arrhythmias, but level of proof remains weak. Calcium channel inhibitors and digoxin are sometimes proposed, albeit in limited situations. It is possible that rest or even heart rate-lowering treatments could help to manage these patients by preventing heart failure as well as by limiting "mechanical inflammation" and controlling arrhythmias, especially life-threatening ones. Whether heart rate has an effect on inflammation remains unclear. Several questions remain unsolved, such as the duration of such treatments, especially in light of new heart rate-lowering treatments, such as ivabradine. In this review, we discuss rest and heart-rate lowering medications for the treatment of pericarditis and myocarditis. We also highlight some work in experimental models that indicates the beneficial effects of such treatments for these conditions. Finally, we suggest certain experimental avenues, through the use of animal models and clinical studies, which could lead to improved management of these patients.
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Affiliation(s)
- François Roubille
- Montreal Heart Institute, Université de Montréal, Montreal, Canada; Cardiology Department, University Hospital of Montpellier, Montpellier, France.
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Affiliation(s)
- J. Reimer
- PO Box 1066; Georgetown; Kentucky; USA
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Khoueiry Z, Roubille C, Nagot N, Lattuca B, Piot C, Leclercq F, Delseny D, Busseuil D, Gervasoni R, Davy JM, Pasquié JL, Cransac F, Sportouch-Dukhan C, Macia JC, Cung TT, Massin F, Cade S, Cristol JP, Barrère-Lemaire S, Roubille F. Could heart rate play a role in pericardial inflammation? Med Hypotheses 2012; 79:512-5. [PMID: 22858356 DOI: 10.1016/j.mehy.2012.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 07/04/2012] [Accepted: 07/08/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED PURPOSE AND MEDICAL HYPOTHESIS: Rest is usually recommended in acute pericarditis, as it could help to lower heart rate (HR) and contribute to limit "mechanical inflammation". Whether HR on admission could be correlated and perhaps participate to inflammation has not been reported. METHODS Between March 2007 and February 2010, we conducted a retrospective study on all patients admitted to our center for acute pericarditis. Diagnosis criteria included two of the following ones: typical chest pain, friction rub, pericardial effusion on cardiac echography, or typical electrocardiogram (ECG) findings. Primary endpoint was biology: CRP on admission, on days 1, 2, 3, and especially peak. RESULTS We included 73 patients. Median age was 38 years (interquartiles 28-51) and median hospitalization duration was 2.0 days (1.5-3.0). Median heart rate was 88.0 beats per minute (bpm) on admission (interquartiles 76.0-100.0) and 72.0 on discharge (65.0-80.0). Heart rate on admission was significantly correlated with CRP peak (p<0.001), independently of temperature on admission, hospitalization duration and age. Recurrences occurred within 1 month in 32% of patients. Heart rate on hospital discharge was correlated with recurrence, independently of age. CONCLUSION In acute pericarditis, heart rate on admission is independently correlated with CRP levels and heart rate on discharge seems to be independently correlated to recurrence. This could suggest a link between heart rate and pericardial inflammation.
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Affiliation(s)
- Ziad Khoueiry
- Cardiology Department, University Hospital of Montpellier, Montpellier, France
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Maestroni S, Di Corato PR, Cumetti D, Chiara DBLC, Ghidoni S, Prisacaru L, Cantarini L, Imazio M, Penco S, Pedrotti P, Caforio ALP, Doria A, Brucato A. Recurrent pericarditis: autoimmune or autoinflammatory? Autoimmun Rev 2012; 12:60-5. [PMID: 22884556 DOI: 10.1016/j.autrev.2012.07.023] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Idiopathic recurrent acute pericarditis (IRAP) represents the most troublesome complication of acute pericarditis and occurs in up to 20-50% of patients. It is generally idiopathic or postcardiac injury. IRAP is a disease of suspected immune-mediated pathogenesis. On the other hand, it has been suggested that some of these patients might have an atypical or subclinical form of an autoinflammatory disease, e.g. genetic disorders characterized by primary dysfunction of the innate immune system and caused by mutations of genes involved in the inflammatory response. We found that IRAP patients were negative for mutations associated with familial Mediterranean fever, but 6% (8/131 patients) carry a mutation in the TNFRSF1A gene, encoding the receptor for tumor necrosis factor-alfa. C-reactive protein (CRP) may be useful to follow the disease activity and guide the appropriate length of therapy, with continuation of the attack doses of the drugs until CRP normalization, at which time tapering may be considered. IRAP often needs a multidrug therapy: NSAIDs or aspirin at high dosages every 6-8h, corticosteroids only rarely, at low dosages and with a very gradual tapering (months) and colchicine at low dosages if tolerated. Anakinra could be a solution for patients who do not tolerate other therapies.
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Treatment with aspirin, NSAID, corticosteroids, and colchicine in acute and recurrent pericarditis. Heart Fail Rev 2012; 18:355-60. [DOI: 10.1007/s10741-012-9328-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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García-Sabina A, Rabuñal Rey R, Martínez-Pacheco R. Revisión sobre el uso de medicamentos en condiciones no incluidas en su ficha técnica. FARMACIA HOSPITALARIA 2011; 35:264-77. [PMID: 21570887 DOI: 10.1016/j.farma.2010.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 06/16/2010] [Accepted: 06/23/2010] [Indexed: 12/18/2022] Open
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Meta-analysis of randomized trials focusing on prevention of the postpericardiotomy syndrome. Am J Cardiol 2011; 108:575-9. [PMID: 21624554 DOI: 10.1016/j.amjcard.2011.03.087] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 03/22/2011] [Accepted: 03/22/2011] [Indexed: 11/20/2022]
Abstract
The natural history of postpericardiotomy syndrome (PPS), a relatively common complication of cardiac surgery, varies from mild self-limited episodes to cases with protracted courses, recurrences, and readmissions. Preventive strategies may be valuable to decrease morbidity and management costs. We thus aimed to conduct a comprehensive systematic review on available data for pharmacologic primary prevention of PPS. Controlled clinical studies were searched in several databases and were included provided they focused on pharmacologic primary prevention of PPS. Random-effect odds ratios (ORs) were computed for occurrence of PPS. From the initial sample of 343 citations, 4 controlled clinical trials for primary prevention of PPS were finally included (894 patients); 3 studies were double-blind randomized controlled trials (RCTs). Treatment comparisons were colchicine versus placebo (2 RCTs enrolling 471 patients), methylprednisolone versus placebo (1 RCT on 246 pediatric patients), and aspirin versus historical controls (1 nonrandomized study on 177 pediatric patients). Meta-analytic pooling showed that colchicine was associated with decreased risk of PPS (OR 0.38, 0.22 to 0.65). Data on methylprednisolone (OR 1.13, 0.57 to 2.25) or aspirin (OR 1.00, 0.16 to 6.11) were negative but inconclusive because these were based on 1 study and/or a nonrandomized design. In conclusion, clinical evidence for primary prevention of PPS is still limited to few studies of variable quality. Nevertheless, available data suggest a beneficial profile for colchicine and open a new therapeutic strategy for prevention of PPS.
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Imazio M, Brucato A, Maestroni S, Cumetti D, Dominelli A, Natale G, Trinchero R. Prevalence of C-Reactive Protein Elevation and Time Course of Normalization in Acute Pericarditis. Circulation 2011; 123:1092-7. [DOI: 10.1161/circulationaha.110.986372] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Massimo Imazio
- From the Cardiology Department (M.I., R.T.) and Central Laboratory (A.D., G.N.), Maria Vittoria Hospital, Torino, Italy; and Division of Internal Medicine, Ospedali Riuniti (A.B., S.M., D.C.), Bergamo, Italy
| | - Antonio Brucato
- From the Cardiology Department (M.I., R.T.) and Central Laboratory (A.D., G.N.), Maria Vittoria Hospital, Torino, Italy; and Division of Internal Medicine, Ospedali Riuniti (A.B., S.M., D.C.), Bergamo, Italy
| | - Silvia Maestroni
- From the Cardiology Department (M.I., R.T.) and Central Laboratory (A.D., G.N.), Maria Vittoria Hospital, Torino, Italy; and Division of Internal Medicine, Ospedali Riuniti (A.B., S.M., D.C.), Bergamo, Italy
| | - Davide Cumetti
- From the Cardiology Department (M.I., R.T.) and Central Laboratory (A.D., G.N.), Maria Vittoria Hospital, Torino, Italy; and Division of Internal Medicine, Ospedali Riuniti (A.B., S.M., D.C.), Bergamo, Italy
| | - Antonio Dominelli
- From the Cardiology Department (M.I., R.T.) and Central Laboratory (A.D., G.N.), Maria Vittoria Hospital, Torino, Italy; and Division of Internal Medicine, Ospedali Riuniti (A.B., S.M., D.C.), Bergamo, Italy
| | - Giuseppe Natale
- From the Cardiology Department (M.I., R.T.) and Central Laboratory (A.D., G.N.), Maria Vittoria Hospital, Torino, Italy; and Division of Internal Medicine, Ospedali Riuniti (A.B., S.M., D.C.), Bergamo, Italy
| | - Rita Trinchero
- From the Cardiology Department (M.I., R.T.) and Central Laboratory (A.D., G.N.), Maria Vittoria Hospital, Torino, Italy; and Division of Internal Medicine, Ospedali Riuniti (A.B., S.M., D.C.), Bergamo, Italy
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Sheth S, Wang DD, Kasapis C. Current and emerging strategies for the treatment of acute pericarditis: a systematic review. J Inflamm Res 2010; 3:135-42. [PMID: 22096363 PMCID: PMC3218740 DOI: 10.2147/jir.s10268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pericarditis is a common disorder that has multiple causes and presents in various primary-care and secondary-care settings. It is diagnosed in 0.1% of all hospital admissions and in 5% of emergency room visits for chest pain. Despite the advance of new diagnostic techniques, pericarditis is most commonly idiopathic, and radiation therapy, cardiac surgery, and percutaneous procedures have become important causes. Pericarditis is frequently benign and self-limiting. Nonsteroidal anti-inflammatory agents remain the first-line treatment for uncomplicated cases. Integrated use of new imaging methods facilitates accurate detection and management of complications such as pericardial effusion or constriction. In this article, we perform a systematic review on the etiology, clinical presentation, diagnostic evaluation, and management of acute pericarditis. We summarize current evidence on contemporary and emerging treatment strategies.
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Affiliation(s)
- Samar Sheth
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Imazio M, Trinchero R, Brucato A, Rovere ME, Gandino A, Cemin R, Ferrua S, Maestroni S, Zingarelli E, Barosi A, Simon C, Sansone F, Patrini D, Vitali E, Ferrazzi P, Spodick DH, Adler Y. COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS): a multicentre, randomized, double-blind, placebo-controlled trial. Eur Heart J 2010; 31:2749-54. [PMID: 20805112 DOI: 10.1093/eurheartj/ehq319] [Citation(s) in RCA: 177] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIMS No drug has been proven efficacious to prevent the post-pericardiotomy syndrome (PPS), but colchicine seems safe and effective for the treatment and prevention of pericarditis. The aim of the COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS) trial is to test the efficacy and safety of colchicine for the primary prevention of the PPS. METHODS AND RESULTS The COPPS study is a multicentre, double-blind, randomized trial. On the third post-operative day, 360 patients (mean age 65.7 ± 12.3 years, 66% males), 180 in each treatment arm, were randomized to receive placebo or colchicine (1.0 mg twice daily for the first day followed by a maintenance dose of 0.5 mg twice daily for 1 month in patients ≥70 kg, and halved doses for patients <70 kg or intolerant to the highest dose). The primary efficacy endpoint was the incidence of PPS at 12 months. Secondary endpoint was the combined rate of disease-related hospitalization, cardiac tamponade, constrictive pericarditis, and relapses. Baseline characteristics were well balanced between the study groups. Colchicine significantly reduced the incidence of the PPS at 12 months compared with placebo (respectively, 8.9 vs. 21.1%; P = 0.002; number needed to treat = 8). Colchicine also reduced the secondary endpoint (respectively, 0.6 vs. 5.0%; P = 0.024). The rate of side effects (mainly related to gastrointestinal intolerance) was similar in the colchicine and placebo groups (respectively, 8.9 vs. 5.0%; P = 0.212). CONCLUSION Colchicine is safe and efficacious in the prevention of the PPS and its related complications and may halve the risk of developing the syndrome following cardiac surgery. ClinicalTrials.gov number, NCT00128427.
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Affiliation(s)
- Massimo Imazio
- Department of Cardiology, Maria Vittoria Hospital, Via Cibrario 72, 10141 Torino, Italy.
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