Myocarditis and pericardial syndromes

Myocarditis is defined as inflammatory disease of the myocardium, diagnosed by established histological, immunological, and immunohistochemical criteria. Aetiology-targeted therapy is indicated when supported by evidence. However, in the vast majority of patients with myocarditis, the most important targets of treatment are heart failure and arrhythmias. Management of systolic left ventricular (LV) dysfunction should follow the recommendations of current European Society of Cardiology guidelines on heart failure. Immunosuppression is indicated only in giant cell myocarditis. In patients with severe LV dysfunction, inotropic support may be necessary and ventricular assist devices may represent a bridge to recovery or to heart transplantation There are no specific treatments of arrhythmias in myocarditis. Implantation of cardioverter–defibrillators must be deferred in the acute phase. In patients with severe ventricular arrhythmia, a wearable cardioverter–defibrillator can represent a bridge to recovery, implantation of cardioverter–defibrillators, or heart transplantation. Pericardial diseases may be either an isolated disease or part of a systemic disease. The main pericardial syndromes that are encountered in clinical practice include pericarditis (acute, subacute, chronic, and recurrent), pericardial effusion, cardiac tamponade, and constrictive pericarditis, and pericardial masses. Major advances have occurred in therapy with the first multicentre randomized clinical trials. Colchicine has been demonstrated as a first-line drug to be added to conventional anti-inflammatory therapies in patients with a first episode of pericarditis or recurrences, in order to improve response to therapy, increase remission rates, and reduce recurrences.

Myocarditis and pericardial syndromes

Myocarditis is defined as inflammatory disease of the myocardium, diagnosed by established histological, immunological, and immunohistochemical criteria. Aetiology-targeted therapy is indicated when supported by evidence. However, in the vast majority of patients with myocarditis, the most important targets of treatment are heart failure and arrhythmias. Management of systolic left ventricular (LV) dysfunction should follow the recommendations of current European Society of Cardiology guidelines on heart failure. Immunosuppression is indicated only in giant cell myocarditis. In patients with severe LV dysfunction, inotropic support may be necessary and ventricular assist devices may represent a bridge to recovery or to heart transplantation There are no specific treatments of arrhythmias in myocarditis. Implantation of cardioverter–defibrillators must be deferred in the acute phase. In patients with severe ventricular arrhythmia, a wearable cardioverter–defibrillator can represent a bridge to recovery, implantation of cardioverter–defibrillators, or heart transplantation. Pericardial diseases may be either an isolated disease or part of a systemic disease. The main pericardial syndromes that are encountered in clinical practice include pericarditis (acute, subacute, chronic, and recurrent), pericardial effusion, cardiac tamponade, and constrictive pericarditis, and pericardial masses. Major advances have occurred in therapy with the first multicentre randomized clinical trials. Colchicine has been demonstrated as a first-line drug to be added to conventional anti-inflammatory therapies in patients with a first episode of pericarditis or recurrences, in order to improve response to therapy, increase remission rates, and reduce recurrences.

Overview of pericardial syndromes

Pericardial diseases manifest as a part of a systemic condition or in isolation. The clinical presentation is driven by inflammation (i.e. pericarditis), excess fluid accumulation (pericardial effusion), or pericardial stiffening (constriction). Corresponding symptoms and signs may include pain, stigmata of systemic inflammation, atrial arrhythmia, haemodynamic compromise, or chronic heart failure. Pericardial tumours and space-occupying lesions are uncommon and may be incidentally detected or present as one of the above-mentioned forms of pericardial disease. Aetiological work-up is usually unnecessary in acute pericarditis but is indicated in the incessant/chronic form and to exclude bacterial infection. Pericardial effusions need to be investigated when large and promptly evacuated when associated with haemodynamic compromise. The hallmark of constrictive physiology is ventricular interdependence. It is important to distinguish transient constriction and to treat inflammation according to aetiology prior to making a decision on surgical relief by pericardiectomy.

Overview of pericardial syndromes

Pericardial diseases manifest as a part of a systemic condition or in isolation. The clinical presentation is driven by inflammation (i.e. pericarditis), excess fluid accumulation (pericardial effusion), or pericardial stiffening (constriction). Corresponding symptoms and signs may include pain, stigmata of systemic inflammation, atrial arrhythmia, haemodynamic compromise, or chronic heart failure. Pericardial tumours and space-occupying lesions are uncommon and may be incidentally detected or present as one of the above-mentioned forms of pericardial disease. Aetiological work-up is usually unnecessary in acute pericarditis but is indicated in the incessant/chronic form and to exclude bacterial infection. Pericardial effusions need to be investigated when large and promptly evacuated when associated with haemodynamic compromise. The hallmark of constrictive physiology is ventricular interdependence. It is important to distinguish transient constriction and to treat inflammation according to aetiology prior to making a decision on surgical relief by pericardiectomy.

The Role of Colchicine in Pericardial Syndromes

Background: Colchicine is an old drug originally employed for the treatment of inflammatory disorders such as acute gout and familiar Mediterranean fever. Methods: In the past few decades, colchicine has been at the forefront of the pharmacotherapy of several cardiac diseases, including acute and recurrent pericarditis, coronary artery disease, prevention of atrial fibrillation and heart failure. In this review, we have summarized the current evidence based medicine and guidelines recommendations in the specific context of pericardial syndromes. Results: Colchicine has been firstly engaged in the treatment of recurrent pericarditis of viral, idiopathic and autoimmune origin. Shortly thereafter colchicine use has been expanded to the primary prevention of recurrences in patients with a first episode of pericarditis depicting similarly good results. The acquisition of high quality scientific data in the course of time from prospective randomized placebo-controlled trials and metanalyses have established colchicine as first line treatment option in acute and recurrent pericarditis, on top of the conventional treatment. The only concerns related to the use of colchicine are the side effects (mainly gastrointestinal intolerance) which although generally not serious, may account for treatment withdrawal in some cases. Conclusion: Colchicine has been established as a first line medication in the treatment of acute (first episode) and recurrent pericarditis on top of the conventional treatment as well as for the prevention of postpericardiotomy syndrome. It depicts a good safety profile with gastrointestinal intolerance being the most common side effect.