"Pericardial diseases include different clinical presentations and
various aetiologies that require appropriate management," said Professor
Yehuda Adler, Co-Chairperson of the guidelines Task Force. "We hope
these new recommendations will help clinicians to manage these diseases
with resulting improvements in outcomes and quality of life."
The pericardium (meaning "around" and "heart") is a double-walled
sac containing the heart and the roots of the great vessels. It provides
lubrication and protection from infection. Pericardial diseases may be
isolated or part of a systemic disease. The main pericardial syndromes
are pericarditis, pericardial effusion, cardiac tamponade, constrictive
pericarditis and pericardial masses. Medical therapies for this group of
diseases are off-label since no drug has been registered for a specific
Pericarditis accounts for about 5% of emergency room admissions for
chest pain. The long-term prognosis is usually good but recurrences
affect about 30% of patients and quality of life can be extremely
limited with severe physical restrictions and dependence on
There have been major advances in therapy since 2004 with the
publication of the first multicentre randomised clinical trials,
especially on the use of colchicine (commonly used to treat gout). This
drug is now recommended as first line therapy for acute pericarditis as
adjunct to aspirin or NSAIDs and in patients with a first episode or
recurrent acute pericarditis. "This treatment should improve patients'
response to aspirin or NSAIDs, increase remission rates and reduce the
recurrence of pericarditis," said Professor Philippe Charron, Task Force
The guidelines recommend that pregnancy in women with recurrent
pericarditis should be planned during a phase of disease quiescence.
Specific recommendations are given on which medications to use during
pregnancy (before and after 20 weeks), and after delivery during
breastfeeding. For example, aspirin is the first choice before 20 weeks
but should be avoided after 20 weeks and during breastfeeding.
Colchicine is considered contraindicated, even though no adverse events
during pregnancy have been reported in women with familial Mediterranean
fever treated with colchicine during pregnancy and breastfeeding.
Also new are specific diagnostic criteria for acute pericarditis
which is now identified when patients exhibit two of the following:
pericarditic chest pain, pericardial rubs, new widespread ST elevation
or PR depression on an ECG, or pericardial effusion (new or worsening).
Recurrent pericarditis is defined as recurrence of pericarditis after a
documented first episode of acute pericarditis and a symptom-free
interval of at least four to six weeks.
Novel diagnostic strategies are introduced for the triage of
patients with pericarditis and pericardial effusion. These allow the
selection of high-risk patients for treatment and specify when and how
additional diagnostic investigations should be performed. Multimodality
imaging is now an essential part of diagnostic evaluation. Professor
Adler said: "The combination of diagnostic criteria and strategies will
help clinicians to clarify what condition a patient has and provide the
most appropriate therapy."
Despite the emergence of a large amount of new data over the past
ten years, further research is required in a number of areas including
the pathophysiology and risk factors for recurrent pericarditis; how
pericarditis can be prevented if colchicine is ineffective; and the
aetiology, pathophysiology, and management of isolated pericardial
Professor Charron concluded: "The field of pericardial diseases has
seen dramatic improvements since the previous guidelines were published.
The first clinical trials have been performed and put management of
these diseases on the road of evidence based medicine. Patients with
pericardial diseases should now receive more accurate diagnosis and