Episode Of Acute Pericarditis Research Articles

D-dimers as a prognostic plasma biomarker in patients with a first episode of acute pericarditis

Abstract Introduction/Background At present the impact of plasma biomarkers in predicting outcome of patients with isolated acute pericarditis (AP) has been poorly investigated. Purpose This study aimed to investigate the prognostic role of fibrin d-dimers (DD), an easily obtainable biomarker, in patients with AP. Methods This is a prospective clinical study enrolling 265 consecutive patients hospitalized between September 2010 and May 2019 with a first episode of AP. At baseline demographics, clinical features, laboratory, imaging findings and treatment were recorded. All patients were followed-up for a minimum period of 18 months. DD measurement at presentation was at the discretion of the examining physician since their measurement is not performed as per protocol in patients with suspected AP. End-points included cardiac tamponade, new-onset atrial fibrillation, pericardial drainage, recurrent/constrictive pericarditis and death. Results DD were measured in 165 out of 265 patients (62.3%, median levels 1456 ng/ml) at presentation. Among them 121 patients (73.3%) presented with elevated age-adjusted DD levels. Patients with elevated DD compared to those without depicted a higher rate of pleural (69.4%, vs 38.6%, p<0.001) and pericardial effusions (89.3% vs 72.7%, p=0.009). Concerning baseline laboratory values, patients with elevated DD presented with lower hematocrit and higher platelet counts, admission and peak C-reactive protein levels, as well as serum Glutamic pyruvic transaminase (SGPT) (Figure 1). In terms of outcome patients with elevated DD depicted a trend towards a greater prevalence of pericardial tamponade vs those without (14.9% vs 4.5% respectively, p=0.07). No significant difference was observed in the remainder of the endpoints during a median follow-up of 51 months. Notably, 43.8% of patients with elevated DD underwent computed tomography pulmonary angiography (CTPA), with all of the examinations being negative for pulmonary embolism. Conclusion Elevated DD plasma values in AP patients is a marker of high inflammatory burden. A trend of this plasma biomarker elevation and in-hospital cardiac tamponade was also observed. DD elevation in AP patients should be interpreted with caution and should not prompt unnecessary investigations (such as CTPA).

D-dimer as a diagnostic and prognostic plasma biomarker in patients with a first episode of acute pericarditis

ObjectivesThe impact of plasma biomarkers on diagnosis and prognosis of patients with acute pericarditis (AP) has been poorly investigated. This study aims to assess the diagnostic and prognostic role of d-dimer (DD), an easily obtainable biomarker, in patients with AP. Patients and methodsThis is a prospective clinical study enrolling 265 consecutive patients hospitalized between September 2010 and May 2019 with a first episode of AP. At baseline, demographics, clinical features, laboratory and imaging findings were recorded. All patients were followed-up for a minimum of 18 months. Endpoints included cardiac tamponade, new-onset atrial fibrillation, pericardial drainage, recurrent/constrictive pericarditis and death. ResultsDD was measured in 165 out of 265 patients (62.3%, median levels 1456 ng/mL) Among them, 121 patients (73.3%) presented with elevated age-adjusted DD levels. Patients with elevated DD depicted a higher rate of pleural (69.4%, vs 38.6%, p<0.001) and pericardial effusions (89.3% vs 72.7%, p = 0.009). Elevated DD correlated with admission (rho=0.37) and peak (rho=0.36) C-reactive protein values. Patients with elevated DD depicted a trend towards a greater prevalence of pericardial tamponade vs those without (14.9% vs 4.5% respectively, p = 0.07). In the 43.8% of patients with elevated DD who underwent computed tomography pulmonary angiography (CTPA), no case of pulmonary embolism or aortic syndrome was unveiled. ConclusionDD elevation is detected in the majority of AP cases at presentation and may herald cardiac tamponade. In patients with chest pain not attributable to alternative causes, elevated DD denotes an inflammatory condition and should not prompt unnecessary investigations, such as CTPA.

Cardiac MRI after first episode of acute pericarditis: A pilot study for better identification of high risk patients

BackgroundCardiac magnetic resonance (CMR) was proposed as an accurate non-invasive tool to evaluate pericardial inflammation. Aim of the present study was to evaluate the role of CMR early in the course of the first episode of acute pericarditis. Material and methodsA clinical registry of consecutive patients who underwent clinical indicated CMR due to pericardial disease from January 2014 to January 2020 was screened. We analyzed patients with the clinical diagnosis of first episode of acute pericarditis needing hospitalization less than 7 days before CMR. Outcome measures were obtained using a single combined end-point, defined as pericardial event, including all the following: recurrent pericarditis, chronic constrictive pericarditis, surgery for pericardial disease. ResultsTwenty-six patients meet the study criteria and were enrolled. A mean follow-up of 34 ± 7 months was obtained and a second episode of pericardial event were recorded in 9 patients. At multivariate analysis adjusted for propensity score, based on clinical significative variable (younger age and higher CRP) the association between pericardial inflammation identified by CMR (positive late gadolinium enhancement on pericardium) and recurrence of pericardial events was confirmed [OR (95%CI) 8.94 (1.74–45.80), p = 0.008]. ConclusionPericardial inflammation identified by CMR, with LGE images, has a prognostic value independently from clinical and bio-humoral variables.

Abstract 11313: Pericarditis Recurrence After Initial Uncomplicated Clinical Course

Introduction: Acute pericarditis is an inflammatory disease associated with a non-negligible risk of acute complications and future recurrence. The exact incidence of pericarditis recurrence in patients with a first uncomplicated clinical course is, however, unknown. Objectives: We sought to evaluate the incidence and clinical predictors of recurrence after a first episode of acute uncomplicated pericarditis in a large urban hospital in the USA. Methods: We conducted a retrospective review, through electronic health records, to complete a database that includes patients admitted with a first episode of acute pericarditis (according to ESC criteria) and then selected only those with uncomplicated course (without in-hospital death, large pericardial effusion [&gt;20 mm] or tamponade, constriction, or failure of treatment) at the VCU Medical Center (Richmond, VA) between 2009 and 2018. Results: A total of 240 patients met acute pericarditis criteria: 174 (72%) patients had an uncomplicated course (median age was 50 [interquartile range 34 to 62] years, 45% females, 51% Black). Pericarditis was considered idiopathic in 89 patients (51%). During a median follow-up time of 184 [17- 434] days, 23 (13%) patients experienced at least one episode of recurrent pericarditis. When compared with those without recurrence, patients with recurrent pericarditis were more frequently females (15 [65%] vs 63 [42%], p=0.035) and had a higher prevalence of subacute/delayed presentation (defined as symptoms over several days without a clear-cut acute onset) (3 [13%] vs 1 [0.7%], p=0.008). There were no other clinical (including the use of anti-inflammatory therapies and pericarditis etiology) or laboratory differences between those with and without pericarditis recurrence at follow-up. At multivariate logistic regression analysis only subacute presentation remained predictor of recurrence at follow-up (odds ratio 20, 95% confidence interval [1.81-198.11], p=0.014). Conclusions: Approximately one every six patients with an acute pericarditis experience a recurrence over a 6-month median follow-up despite an initial uncomplicated course. Subjects with subacute presentation were at significantly higher risk of recurrence.

Development of a risk-score for pericarditis recurrence in patients with a first episode of acute pericarditis

Abstract Background/Introduction Currently we remain uncertain about which patients are at increased risk for recurrent pericarditis. Purpose We developed a risk score for pericarditis recurrence in patients with acute pericarditis. Methods We prospectively recruited 262 patients with acute pericarditis. Patients' demographics, clinical, imaging and laboratory data at presentation, were collected. Patients were followed-up for a median of 51 months (interquartile range 21–71) for recurrence. Variables with &amp;lt;10% missingness were entered into multivariable logistic regression models with stepwise elimination to explore independent predictors of recurrence. The performance of the final model was assessed by the c-index and model's calibration and the optimism corrected c-index were evaluated after 10-fold cross-validation. Results We identified six independent predictors for pericarditis recurrence i.e., age, effusion size, platelet count (negative predictors) and reduced inferior vena cava collapse, in-hospital use of corticosteroids, and heart rate (positive predictors). The final model had good performance for recurrence, c-index 0.783 (95% CI 0.725–0.842), while the optimism corrected c-index after cross-validation was 0.752. Based on these variables we developed a risk score point system for recurrence (0–22 points) with equally good performance (c-index 0.740, 95% CI 0.677–0.803). Patients with a low score (0–7 points) had 21.3% risk for recurrence, while those with high score (≥12 points) had a 69.8% risk for recurrence (Figure 1). The score was predictive of recurrence among most patient subgroups. Conclusions A simple risk score point system based on 6 variables can be used to predict the individualized risk for pericarditis recurrence among patients with a first episode of acute pericarditis. Funding Acknowledgement Type of funding sources: None. Figure 1

Prognostic role of cardiac MRI after first episode of acute pericarditis: a long-term follow-up study

Abstract Introduction Recurrent pericarditis (RP) complicates acute pericarditis in 30% of case. In this clinical setting guidelines suggest a one fits-all therapeutical approach, but only a minority of patients had RP. Pericardial LGE at cardiac MRI has been suggested as potential predictor of worse prognosis among patients with RP while no data are available regarding the role of CMR after first episode of pericarditis. Aim of the present study is to evaluate the role of cardiac MRI after a single episode of pericarditis for the identification of patients at higher risk of recurrent pericarditis that may merit more aggressive therapy. Material and methods From a registry of consecutive patients who underwent cardiac MRI from January 2014 to January 2019 we retrospectively selected a subgroup of patients with clinical diagnosis of pericarditis according ESC guidelines on pericardial disease, who underwent cardiac CMR less than 2 week after symptoms onset, for which transthoracic echocardiography and biochemical data during acute episode were available. CMR protocol included bSSFP images, T2w images and LGE in all patients. Transthoracic echocardiography was considered to be positive for pericardial disease if pericardial effusion and/or signs of pericardial constriction were present; cardiac MRI was considered to be positive for pericardial inflammation if pericardial hyperintensity signal were detected on T2w or LGE images. Clinical follow-up was recorded for a composite end-point including new episodes of recurrent pericarditis and subsequent diagnosis of chronic constrictive pericarditis Results A total of 26 patients were included in the study. All patients presented high risk features according to ESC guidelines on pericarditis. Pericarditis etiology was unknow (idiopathic) in 22 (84.6%), related to cancer in 3 patients (11.6%) post-myocardial injury in 1 case (3.8%). In 6 patients (24%) a myopericarditis was diagnosed. According to predefined criteria 12 patients had echocardiography positive for pericardial disease (46.2%), while in 7 patients cardiac MRI was positive for pericardial inflammation (26.9%). Both echocardiography and cardiac MRI were positive in 5 patients (19.2%). At a mean follow-up of 46.2±21.2 months a total of 8 recurrent pericarditis events were recorded and 1 patient developed chronic constrictive physiology. When corrected for peak C-reactive protein values, MRI positive for pericardial inflammation [HR (95% CI) 5.5 (1.3–24.1), p=0.034] but not echocardiography positive for pericardial disease [HR (95% CI) 0.58 (0.1–2.8), p=0.507] resulted to be associated to composite end-point at follow-up. Conclusion Cardiac MRI positive for pericardial inflammation may identify patients at higher risk for recurrent pericarditis, independently from peak C-reactive protein values, even after the first episode of acute pericarditis Funding Acknowledgement Type of funding sources: None.

Pericarditis Recurrence After Initial Uncomplicated Clinical Course

Acute pericarditis is an inflammatory disease associated with a non-negligible risk of acute complications and future recurrence. However, the exact incidence of pericarditis recurrence in patients with a first uncomplicated clinical course is unknown. We sought to evaluate the incidence and clinical predictors of recurrence after a first episode of acute uncomplicated pericarditis in a large urban hospital in the United States. We conducted a retrospective review, through electronic health records, to complete a database that includes patients admitted with a first episode of acute pericarditis and selected only those with an uncomplicated course (without in-hospital death, large pericardial effusion [>20 mm] or tamponade, constriction, or incessant pericarditis) at the VCU Medical Center (Richmond, Virginia) from 2009 to 2018. A total of 240 patients met acute pericarditis criteria: of the 240 patients, 164 patients (68%) had an uncomplicated course (median age [interquartile range] in years: 50 [32 to 62], 43% females). The median follow-up time was 186 (19 to 467) days. Pericarditis was idiopathic in 84 patients (51%). Fifteen patients (9%) had at least 1 episode of recurrent pericarditis. Compared with those without recurrence, patients with recurrent pericarditis were younger (37 [25 to 59] vs 51 [34 to 62] years, p=0.034), had a higher prevalence of subacute/delayed presentation (2 [13%] vs 1 [1%], p=0.023), and less frequently received colchicine (6 [40%] vs 100 [67%], p=0.036). At multivariate logistic regression analysis, subacute presentation and younger age remained predictors of recurrence at follow-up. In conclusion, 9% of patients with acute pericarditis experienced a recurrence over a 6-month median follow-up despite an initial uncomplicated course. Younger age and subacute presentation were associated with a significantly increased risk of recurrence.

Emerging Therapies for Recurrent Pericarditis: Interleukin-1 inhibitors.

Recurrent pericarditis (RP) is a complex inflammatory disorder associated with adverse outcomes and poor quality of life. After the first episode of acute pericarditis, a non‐negligible group of patients will fail to achieve complete remission despite treatment and will be challenged by side effects from the chronic use of medications like corticosteroids. The cause of RP remains unknown in the majority of cases, mainly due to a gap in knowledge of its complex pathophysiology. Over the past 2 decades, the interleukin‐1 (IL‐1) pathway has been uncovered as a key element in the inflammatory cascade, allowing the development of pharmacological targets known as IL‐1 inhibitors. This group of medications has emerged as a treatment option for patients with RP colchicine‐resistance and steroid dependents. Currently, anakinra and rilonacept, have demonstrated beneficial impact in clinical outcomes with a reasonable safety profile in randomized clinical trials. There is still paucity of data regarding the use of canakinumab in the treatment of patients with RP. Although further studies are needed to refine therapeutic protocols and taper of concomitant therapies, IL‐1 inhibitors, continue to consolidate as part of the pharmacological armamentarium to manage this complex condition with potential use as monotherapy. The aim of this review is to highlight the role of IL‐1 pathway in RP and discuss the efficacy, safety, and clinical applicability of IL‐1 inhibitors in the treatment of RP based on current evidence.

A risk score for pericarditis recurrence.

Currently, we remain uncertain about which patients are at increased risk for recurrent pericarditis. We developed a risk score for pericarditis recurrence in patients with acute pericarditis. We prospectively recruited 262 patients with a first episode of acute pericarditis. Baseline patients' demographics, clinical, imaging and laboratory data were collected. Patients were followed up for a median of 51months (interquartile range 21-71) for recurrence. Variables with <10% missingness were entered into multivariable logistic regression models with stepwise elimination to explore independent predictors of recurrence. The final model performance was assessed by the c-index whereas model's calibration and optimism-corrected c-index were evaluated after 10-fold cross-validation. We identified six independent predictors for pericarditis recurrence, that is age, effusion size, platelet count (negative predictors) and reduced inferior vena cava collapse, in-hospital use of corticosteroids and heart rate (positive predictors). The final model had good performance for recurrence, c-index 0.783 (95% CI 0.725-0.842), while the optimism-corrected c-index after cross-validation was 0.752. Based on these variables, we developed a risk score point system for recurrence (0-22 points) with equally good performance (c-index 0.740, 95% CI 0.677-0.803). Patients with a low score (0-7 points) had 21.3% risk for recurrence, while those with high score (≥12 points) had a 69.8% risk for recurrence. The score was predictive of recurrence among most patient subgroups. A simple risk score point system based on 6 variables can be used to predict the individualized risk for pericarditis recurrence among patients with a first episode of acute pericarditis.

Abstract 16857: Acute Pericarditis With Concomitant Stemi Associated With Delayed Presentation in the Setting of SARS-COV-2 Pandemic

Background: The classic ST-segment elevations seen in a STEMI can similarly be found during an episode of acute pericarditis, making the two entities difficult to distinguish. The incidence of post-myocardial infarction injury syndromes presenting with findings such as acute pericarditis is estimated to be around 3%. Prompt seek of medical care is pivotal in successful outcomes, which has been affected during the pandemic. Case: A 30-year-old female with a past medical history of uncontrolled type 1 diabetes, chronic kidney disease, obesity presented with a 24-hour long history of non-radiating chest pain. Upon interrogation she endorsed that initially she delayed her coming presentation to the hospital because of fears of contracting coronavirus. Physical examination showed tachycardia and tachypnea. EKG demonstrated diffuse ST elevations in the anterolateral leads concerning for a STEMI, PR-segment depressions on most leads and troponin elevation to 0.09 ng/ml. Point of care ultrasound (POCUS) echocardiogram showed significant anterolateral wall hypokinesis. Decision making: Given her high cardiovascular risk factors the patient was urgently taken to the catheterization laboratory which found a 100% ostial left anterior descending artery and a large left main coronary artery thrombus. The thrombus was initially treated with mechanical thrombectomy and the plaque with a percutaneous coronary intervention (PCI) with a drug-eluding stent to the proximal LAD. In the days following her PCI, the patient continued to endorse sporadic sharp chest pain with the same characteristics as on presentation. Post-PCI transthoracic echocardiogram demonstrated ejection fraction of 20-25% and a small pericardial effusion. She was started on colchicine for pericarditis. She was discharged home on dual antiplatelet therapy with close follow up. Conclusion: Given that our patient had clinical pericarditis before her presentation to the hospital with a STEMI, it is unlikely that her pericarditis was due to a post myocardial infarction syndrome. Delayed presentation to the hospital associated with fear of contracting or spreading COVID-19 is a silent collateral culprit that adds up to increased cardiovascular morbidity and mortality during this pandemic.

Age- and sex-based differences in patients with acute pericarditis.

Acute pericarditis has a wide spectrum of clinical presentations largely depending on underlying aetiologies. We assessed the role of age and sex in the clinical features and outcome of acute pericarditis. A total of 240 consecutive patients hospitalized with a first episode of acute pericarditis were included. At baseline demographics, clinical features, laboratory and imaging findings and medical therapy were recorded. Patients were followed up for at least 18months for complications. Data comparisons were performed according to sex and age (≤60 or >60years). The male/female ratio was 1.42, and 56% of patients were >60years. Younger patients depicted more often chest pain (P=.001), fever and rubs (P<.001 for both), ST elevation and PR depression (P=.032 and .009, respectively), higher CRP values (P=.009) and less often dyspnoea (P=.046) and pericardial effusion (P=.036). Moreover, they received less often glucocorticoids (P<.001) and depicted less atrial fibrillation (P=.003) and a higher rate of recurrent pericarditis (P=.013). After multivariate adjustment for confounders, age >60years remained an independent predictor for a lower risk of recurrent pericarditis (hazard ratio 0.60, 95% CI: 0.39-0.96, P=.033). Regarding sex, females were older (P=.007), showed less often ST elevation and PR depression (P<.001 and .002, respectively) and had a higher baseline heart rate (P=.02). Sex was not associated with recurrent pericarditis risk. Patients with acute pericarditis have distinct presenting clinical, biochemical and prognostic features according to age and sex. Awareness of such differences is important for clinical decision-making.

ACUTE ST-ELEVATION WITH CONSTRICTIVE PERICARDITIS: A UNIFYING DIAGNOSIS OR TWO SEPARATE ENTITIES?

Constrictive pericarditis occurs in less than 2% of patients after an episode of acute pericarditis. Up to 26% of patients with constrictive pericarditis are found to have an underlying malignancy. A 75 y/o male with recent acute pericarditis and pericardial window presented in cardiogenic shock.

Clinical significance of pleural effusions and association with outcome in patients hospitalized with a first episode of acute pericarditis.

The clinical significance of pleural effusions (PLEs) in the setting of acute pericarditis remains poorly investigated. We sought to identify predictive factors for PLEs and their association with the short- and long-term prognosis of patients with acute pericarditis. We enrolled 177 patients hospitalized with a first episode of acute pericarditis. In all cases an extensive clinical, biochemical, and diagnostic work-up to detect PLEs and establish etiological diagnosis was performed. All patients included were prospectively followed for a maximum of 18months (median 12, range 1-18) and complications were recorded. PLEs were detected in n = 94 cases (53.1% of the cohort; bilateral 53.2%, left-sided 28.7%, right-sided 18.1%) and were strongly associated with c-reactive protein (CRP) levels at admission (rho = 0.328, p < 0.001). In multivariate logistic regression, independent predictors for PLEs were female gender (OR = 2.46, 95% CI 1.03-5.83), age (per 1-year increment OR = 1.030, 95% CI 1.005-1.056), CRP levels (per 1mg/L increment OR = 1.012, 95% CI 1.006-1.019) and size of pericardial effusion (per 1cm increment, OR = 1.899, 95% CI 1.228-2.935). Bilateral PLEs were associated with increased risk for in-hospital cardiac tamponade (OR = 7.52, 95% CI 2.16-26.21). There was no association of PLEs with new onset atrial fibrillation or pericarditis recurrence during long-term follow-up (χ2 = 0.003, p = 0.958). We conclude that PLEs are common in patients hospitalized with a first episode of acute pericarditis. They are related to the intensity of inflammatory reaction, and they should not be considered necessarily as a marker of secondary etiology. Bilateral PLEs are associated with increased risk of in-hospital cardiac tamponade, but do not affect the long-term risk of pericarditis recurrence.

EFFECT OF ANAKINRA ON COLCHICINE RESISTANT AND STEROID DEPENDENT RECURRENT PERICARDITIS: A SYSTEMIC REVIEW AND META-ANALYSIS

Recurrent pericarditis affects up to 30% patients after the first episode of acute pericarditis. A probable autoinflammatory etiology has triggered the use of Anakinra (IL1 receptor antagonist) for idiopathic recurrent pericarditis particularly in patients with colchicine resistance and

Interleukin-1 blockade for the treatment of pericarditis.

Pericarditis is a debilitating condition that results from profound inflammation of the pericardial tissue. Between 10 and 15% of first episodes of acute pericarditis will be followed by several episodes refractory to conventional treatment. Current standard of care for pericarditis treatment includes high-dose non-steroidal anti-inflammatory drugs, colchicine, and systemic corticosteroids, each associated with potentially severe toxicities and nominal efficacy. Interleukin-1 (IL-1), an apical pro-inflammatory cytokine, plays an important role as an autocrine magnifier of systemic inflammation in pericarditis. Interruption of the IL-1 circuit has been shown to have a favourable risk profile in several disease states. In this review, we discuss the growing body of evidence which supports the use of IL-1 blockade in the treatment of recurrent pericarditis as well as provide practical considerations for the use of IL-1 blockade in clinical practice.

Colchicine for acute pericarditis. Results from the Investigation on Colchicine in Acute Pericarditis (ICAP). A prospective, randomized, double-blind, placebo-controlled, multicenter trial

Purpose: Despite a large amount of data on recurrent pericarditis, conclusive data are lacking to demonstrate the efficacy and safety of colchicine for the treatment of the first attack of acute pericarditis. The Investigation on Colchicine in Acute Pericarditis (ICAP) trial is a prospective, randomized, double-blind, placebo-controlled, multicenter trial aimed at the evaluation of the efficacy and safety of colchicine to treat acute pericarditis and prevent its recurrences. Methods: Eligible adult patients with acute pericarditis were randomly assigned to placebo or colchicine (0.5 mg twice daily for 3 months for patients>70kg or 0.5 mg once daily if ≤70kg) in addition to conventional anti-inflammatory therapy with aspirin or ibuprofen in a multicenter, double-blind, placebo-controlled trial. The primary study outcome was incessant/recurrent pericarditis within 18 months. Secondary outcomes were symptoms persistence at 72 hours, remission within 1 week, number of recurrences, time to first recurrence, disease-related hospitalization, cardiac tamponade, and constrictive pericarditis. Results: Of the 240 randomly assigned participants (mean age 52.1±16.9 years, 60% males), 65 patients (27.1%) reached the primary outcome: incessant/recurrent pericarditis within 18 months was 16.7% in the colchicine group and 37.5% in the placebo group (relative risk reduction 0.56 95% CI 0.30-0.72; number needed to treat-NNT 4). Colchicine reduced symptoms persistence at 72 hours (respectively, 19.2% vs. 40.0%; p=0.001), number of recurrences, hospitalizations (respectively, 5.0% vs. 14.2%; p=0.016), improved the remission rate at 1 week (respectively, 85.0% vs. 58.3%; p<0.001), and prolonged time to first recurrence. Corticosteroid use (OR 4.17, 95% CI 1.28 to 13.53; p=0.018), and C-reactive protein elevation at presentation (OR 3.15, 95% CI 1.05 to 9.49; p=0.041) were independent risk factors for recurrences in multivariable analysis. Overall adverse effect rates were similar in the study groups (respectively, 11.7% in the colchicine group and 10.0% in the placebo group; p=0.836) as well as withdrawal rates (respectively, 11.7% vs. 8.3%; p=0.519). No serious adverse effects were observed. Conclusions: The ICAP trial is the first multicenter, double-blind, randomized trial to show the efficacy and safety of colchicine as an adjunct to conventional anti-inflammatory therapy to halve incessant/recurrent pericarditis within 18 months, reduce the number of recurrences, and prolong the time to subsequent recurrence after a first episode of acute pericarditis. ClinicalTrials.gov [NCT00128453][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00128453&atom=%2Fehj%2F34%2Fsuppl_1%2F877.atom

Thirty year experience of constrictive pericarditis: one-hundred and forty cases with a long-term follow-up

Objectives and methods: 1. To describe the clinical presentation, etiology, diagnostic tecniques, surgical findings and long-term follow-up of patients operated of Constrictive Pericarditis (CP). 2. To identify independent predictors of poor outcome after pericardiectomy. Retrospective analysis of all operated cases of CP: Clinical data, surgical findings and follow-up (FU) were recorded. Results: Between 1978 and 2012, 140 patients underwent pericardiectomy for CP (Male = 99 (71%), age=54 years-old, range (17-80y). Clinical presentation: Congestive heart failure (124p, 87%), chest pain (46p, 33%) or fever (33, 23.4%). Forty-nine patients (35%) were in an advanced NYHA class (III or IV) before surgery. The most frequent etiology of CP was idiopatic (71%). In patients with a specific cause of CP, tuberculosis (11%) was the most frequent diagnosis. Sixteen patients (11%) died perioperatively. Predictors of perioperative mortality were age (66±11 vs 53±16 years, p=0.002), NYHA status III or IV (31% vs 62%, p=0.014) and presence of pericardial effusion (27% vs 60%, p=0.01). Overall mortality during FU (12 years (range 0.1 to 34.5y)) was 39%. Long-term FU analysis (124 patients) showed that independent predictors of death were age at surgery (HR 1.05, 95% CI: 1.017-1.088), a previous episode of acute pericarditis (HR 2.93, 95% CI 1.26-6.81) and a preoperative NYHA status III or IV (HR 4.03, 95% CI 1.79-9.05). Etiology did not have an impact neither in perioperative survival nor in the long-term FU. View this table: Use of diagnostic procedures Conclusions: Idiopatic pericarditis is the most frequent cause of CP. Perioperative mortality is high. Factors associated with a poor perioperative outcome are age, advanced NYHA status and moderate or severe pericardial effusion. Long-term FU shows that independent predictors of poor outcome are age at surgery, advanced NYHA status and a previous episode of acute pericarditis.

Successful treatment of adult patients with idiopathic recurrent pericarditis with an interleukin-1 receptor antagonist (anakinra)

Idiopathic recurrent pericarditis (IRP) is observed in 10–30% of cases after a first episode of acute pericarditis, whereas a second recurrence appears in anevenhigher rate (~50%) [1,2]. Although severalmechanisms have been suggested to explain recurrence, most of them appear simply contributory. Today, there is increasing evidence that autoimmune and autoinflammatory pathways aremainly involved in its pathogenesis [3,4]. The optimal regimen for treating IRP has not been established [1]. Several medications either alone or in combination have been tested including nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin, colchicine, corticosteroids, and immunosuppressive agents. To date, the only available medication proved in randomized trials to decrease the recurrence rate is colchicine [2]. However, even with colchicine, a substantial proportion of patients experience recurrences [2]. Recently, Picco and et al. reported the successful use of an interleukin1β receptor antagonist anakinra in three children with resistant IRP [4]. Here, we present our experience in three adults with drug resistant or intolerant IRP. All patients were informed in detail regarding the management with anakinra and gave informed consent. Case#1: A 26-year-oldmale had suffered 8 episodes of IRP since 2004. He has received various regimens including NSAIDs, colchicine, steroids and azathioprine (Fig. 2A). In October 2006 treatment with prednisone was instituted but his symptoms recurred every time the dose was tapered below 15mg/day. Unfortunately, the patient developed steroidrelated complications including glaucoma, osteopenia and proximal myopathy of the lower extremities. In his latest admission inMarch 2010, the patient was started on anakinra (150 mg/day subcutaneously, SC) as monotherapy for 3 months and steroidswere tapered off. Administration of anakinrawas followed byan immediate and dramatic clinical response International Journal of Cardiology 160 (2012) 66–77

Colchicine is safe and effective for secondary prevention of recurrent pericarditis

The CORP (COlchicine for Recurrent Pericarditis) trial [7]is a prospective, randomized, double-blind, placebo controlled, multicenter trial to evaluate the efficacy and safety of colchicine (1.0–2.0 mg on the first day, followed by a maintenance dose of 0.5–1.0 mg/day for 6 months) in association with conventional anti-inflammatory therapy for the secondary prevention of recurrence in patients with a first relapse of pericarditis. Patients were excluded if they were having their first episode of acute pericarditis, or their second or subsequent recurrence, or had pericarditis with tuberculous, purulent, or neoplastic causes. The primary study end point was the recurrence rate at 18 months. Secondary end points were symptom persistence after 72 h, remission rate at 1 week, number of recurrences, time to first recurrence, disease-related hospitalizations,cardiac tamponade, and constrictive pericarditis rates.120 patients (60 in the colchicine and 60 in the placebo group) were included in the analysis. The recurrence rate is 24 % in the colchicine group and 55 % in the placebo group (absolute risk reduction 0.31 [95 % CI 0.13–0.46];relative risk reduction 0.56 [0.27–0.73]; number needed to treat 3 [2–7]). Colchicine improves the persistence of symptoms at 72 h (absolute risk reduction 0.30 [95 % IC,0.13–0.45]; relative risk reduction 0.56 [0.27–0.74]). It also reduces the mean number of recurrences, increases the remission rate at 1 week and prolongs the time to subsequent recurrence. Colchicine and placebo groups have similar rates of side effects (7 %) and drug withdrawal (8 vs. 5 %, P = 0.89);no severe side effects occurred in any of the groups. Gastrointestinal intolerance was the main side effect during the study.

Risk of Constrictive Pericarditis After Acute Pericarditis

Constrictive pericarditis (CP) is considered a rare, dreaded possible complication of acute pericarditis. Nevertheless, there is a lack of prospective studies that have evaluated the specific risk according to different etiologies. The aim of this study is to evaluate the risk of CP after acute pericarditis in a prospective cohort study with long-term follow-up. From January 2000 to December 2008, 500 consecutive cases with a first episode of acute pericarditis (age, 51±16 years; 270 men) were prospectively studied to evaluate the evolution toward CP. Etiologies were viral/idiopathic in 416 cases (83.2%), connective tissue disease/pericardial injury syndromes in 36 cases (7.2%), neoplastic pericarditis in 25 cases (5.0%), tuberculosis in 20 cases (4.0%), and purulent in 3 cases (0.6%). During a median follow-up of 72 months (range, 24 to 120 months), CP developed in 9 of 500 patients (1.8%): 2 of 416 patients with idiopathic/viral pericarditis (0.48%) versus 7 of 84 patients with a nonviral/nonidiopathic etiology (8.3%). The incidence rate of CP was 0.76 cases per 1000 person-years for idiopathic/viral pericarditis, 4.40 cases per 1000 person-years for connective tissue disease/pericardial injury syndrome, 6.33 cases per 1000 person-years for neoplastic pericarditis, 31.65 cases for 1000 person-years for tuberculous pericarditis, and 52.74 cases per 1000 person-years for purulent pericarditis. CP is a relatively rare complication of viral or idiopathic acute pericarditis (<0.5%) but, in contrast, is relatively frequent for specific etiologies, especially bacterial.