A risk score for pericarditis recurrence.

BACKGROUND: 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. MATERIALS AND METHODS: 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 51 months (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. RESULTS: 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. 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.

Clinical Presentation and Outcomes of Acute Pericarditis in a Large Urban Hospital in the United States of America.

BACKGROUND: Acute pericarditis is the most common presentation of pericardial diseases. Although generally benign, complications such as constrictive pericarditis, cardiac tamponade, and recurrence can occur. RESEARCH QUESTION: What are the clinical factors associated with adverse outcomes in acute pericarditis? STUDY DESIGN AND METHODS: We used an informatics-based search engine to search for International Classification of Diseases codes related to pericardial disease between January 1, 2009 and November 14, 2018 and then extracted clinical information, including only patients meeting the European Society of Cardiology criteria for acute pericarditis. We then evaluated the predictive value of clinical characteristics for adverse outcomes (cardiac tamponade, constrictive pericarditis, failure of therapy, recurrences, or death). RESULTS: We identified 240 patients with a first episode of pericarditis (51 [34-62] years, 56% males and 50% white). Pericarditis was determined to be idiopathic in 126 (53%) cases and related to cardiac injury in 79 (33%). During a median follow-up time of 179 (20-450) days, 82 (34%) patients experienced at least one adverse outcome. Subacute presentation was an independent predictor of adverse outcomes. Patients with postcardiac injury pericarditis had a lower incidence in the composite of failure of treatment and recurrence (13% vs 26%; P = .022) compared with patients with idiopathic pericarditis. Troponin I measurements were obtained in 167 patients (70%). Elevated troponin I levels were associated with lower incidence of recurrences (4% vs 17%; P = .024) and of the composite outcome (13% vs 36%; P = .004). INTERPRETATION: Acute pericarditis is associated with at least one adverse outcome in 34% of patients. Subacute presentation and idiopathic etiology are associated with higher incidence of adverse outcomes, whereas elevated troponin I levels identify a group with reduced risk of recurrences.

Usefulness of Interleukin-1 Receptor Antagonists in Patients With Recurrent Pericarditis.

Nonsteroidal anti-inflammatory drugs and colchicine remain the standard of care as the initial treatment of acute pericarditis. Corticosteroids and traditional immunosuppressive medications are often added if patients develop recurrent symptoms and remain medically refractory. There has been growing interest in the use of interleukin-1 receptor antagonists (IL-1RAs) in managing pericarditis, especially, in medically refractory cases. Anakinra-Treatment for Recurrent Idiopathic Pericarditis is a recent pilot trial showing a benefit of using the IL-1RA, anakinra, in recurrent pericarditis. Publications remain limited and more outcomes trials are needed. This review focuses on the mechanism of action, clinical utility, current, and future studies that investigate the role of IL-1RAs in the management of recurrent pericarditis.

Myocardial injury and pericarditis after combined left atrial and coronary sinus ablation in Wolff-Parkinson-White syndrome: a case report.

BACKGROUND: Radiofrequency catheter ablation is an established procedure with a high success rate for treating Wolff-Parkinson-White (WPW) syndrome. Rare complications post-ablation may nonetheless occur particularly associated with coronary sinus. Identifying and avoiding these complications remains a challenge. CASE PRESENTATION: A 66-year-old woman with WPW syndrome was admitted to the hospital due to frequent attacks of paroxysmal tachycardia. During electrophysiological study, an accessory pathway was thought to connect the posterior wall of the left ventricle. The patient underwent Radiofrequency (RF) catheter ablation. The procedure was time-consuming because of combined left atrial and coronary sinus ablation. The total amount of radiofrequency application energy in the coronary sinus was 6800 J. After the operation, widespread concave ST-segment elevation, significantly increased value of serum troponin I and mild pericardial effusion were identified, but the patient did not show any symptoms. Therefore, the patient was suspected to have myocardial injury and pericarditis caused by ablation-related injury. The patient was uneventfully discharged five days after the procedure with a significantly decreased value of troponin I. The reexamined electrocardiogram was normal after three weeks. CONCLUSIONS: To the best of our knowledge, this is the first study to report on myocardial injury and pericarditis after combined left atrial and coronary sinus ablation in WPW syndrome. Our findings underscore the need for detailed mapping and careful ablation with low energy, as well as the merits of identifying myocardial infarction after coronary sinus ablation.

Prognostic and Diagnostic Significance of Serum High-Sensitivity C-Reactive Protein Level in Patients with Acute Idiopathic Pericarditis.

BACKGROUND: The frequency of increased high-sensitivity C-reactive protein (hs-CRP) and the time course of evolution of their levels in patients with acute idiopathic pericarditis (AIP) are not well established. OBJECTIVES: To assess the time course of evolution of hs-CRP levels and the possible clinical significance of maximal hs-CRP levels in patients with AIP. METHODS: We retrospectively reviewed the medical files of 241 patients admitted to the hospital with a diagnosis of AIP between March 2006 and March 2017. Data on demographics, time of symptom onset, laboratory and imaging findings, and outcome were collected. RESULTS: Data on serum hs-CRP levels were available for 225 patients (age 18-89 years, 181 men). Fever, pleural effusion, and age were independently associated with hs-CRP levels. Major cardiac complications (MCC) (death, cardiac tamponade, cardiogenic shock, large pericardial effusion, ventricular tachycardia, pericardiocentesis, or pericardiectomy) were more common in patients with hs-CRP levels above the median compared to those below (21.2% vs. 4.5%, respectively, P < 0.001). Hs-CRP levels were independently associated with MCC (odds ratio [OR] 1.071, 95% confidence interval [95%CI] 1.016-1.130, P = 0.011). Hs-CRP levels were elevated in 76.0%, 92.3% and 96.0% of the patients tested <6 hours, 7-12 hours, and >12 hours of symptom onset, respectively (P = 0.003). The frequency of elevated hs-CRP among patients tested > 24 hours was 98.1%. CONCLUSIONS: Hs-CRP levels rise rapidly among patients with AIP. Maximal hs-CRP levels are associated with MCC. A normal hs-CRP level is rare among patients tested > 24 hours of symptom onset.

The diagnostic value of the serum irisin level in patients with acute pericarditis and acute myopericarditis.

OBJECTIVE: This preliminary study aims to examine a change in the blood levels of irisin in patients with acute pericarditis (AP) and acute myopericarditis (AMP) and examine the diagnostic value of the serum irisin level in AP and AMP. METHODS: 10 patients, who applied to the emergency service and cardiology clinic with chest pain and who were diagnosed with AP and 5 patients, who were diagnosed with AMP as a result of routine examinations, were included in the study. The basal laboratory parameters, echocardiography findings and serum irisin levels of the patients and during check one month later were examined. RESULTS: While the basal irisin levels were found to be significantly low in the AMP group and high during the check (6.6 ± 1.58, 8.19 ± 1.43, respectively), no statistically significant difference was determined (p = 0.23). It was observed that the basal and control irisin levels did not vary significantly in the AP group (8.03 ± 1.6, 8.19 ± 1.43, respectively) (p = 0.84). CONCLUSION: In this preliminary study, the basal irisin levels were found to be significantly low in the AMP group, while there was no statistically significant difference between the basal irisin levels and control irisin levels in the AP and AMP groups (Tab. 5, Ref. 17).

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.

Cardiovascular complications in paediatric-onset systemic lupus erythematosus in Saudi Arabian patients.

OBJECTIVES: To assess the prevalence and types of cardiovascular complications in Saudi patients with paediatric-onset systemic lupus erythematosus (pSLE). METHODS: Retrospective record review of pSLE patients following from January 2014 to September 2015 at the rheumatology clinic of King Abdul-Aziz University Hospital, Jeddah. Laboratory data such as C-reactive protein (CRP), antinuclear antibodies (ANA), anti-double stranded DNA antibody (anti-dsDNA), C3 and C4 complements, were collected. Cardiac evaluation included chest x-ray, electrocardiogram (ECG), and echocardiography, along with estimation of SLE activity by calculating the SLE Disease Activity Index (SLEDAI) score according to SELENA modification. RESULTS: Forty-six cases of pSLE were included (91.3% females, mean±SD age at diagnosis=10.53±2.28 years). Prevalence of cardiac manifestations was 47.8%; the most frequent of which were valvular heart diseases diagnosed in 16 (34.8%) cases, followed by pericarditis in 6 (13%) cases. Of the 16 valvular diseases, tricuspid and pulmonary valves were involved in 9 and 8 cases, respectively. Cardiac involvement was silent in 36.4% and occurred as an initial presenting symptom of SLE in 9.1% cases. Biologically, patients with cardiac involvement had higher levels of CRP and anti dsDNA, and lower levels of complement C3 compared to patients with no cardiac involvement; while high SLE activity was the only significant predictor for cardiac involvement (beta=0.654; p=0.020). CONCLUSIONS: Cardiac complications are common in Saudi children with pSLE and are asymptomatic in 1 out of 3 times. They are predicted by high SLE activity and associate with high anti-dsDNA and CRP and low C3 levels.

Metabolites as biomarkers of adverse reactions following vaccination: A pilot study using nuclear magnetic resonance metabolomics.

An Adverse Event Following Immunization (AEFI) is an adverse reaction to a vaccination that goes above and beyond the usual side effects associated with vaccinations. One serious AEFI related to the smallpox vaccine is myopericarditis. Metabolomics involves the study of the low molecular weight metabolite profile of cells, tissues, and biological fluids, and provides a functional readout of the phenotype. Metabolomics may help identify a particular metabolic signature in serum of subjects who are predisposed to developing AEFIs. The goal of this study was to identify metabolic markers that may predict the development of adverse events following smallpox vaccination. Serum samples were collected from military personnel prior to and following receipt of smallpox vaccine. The study population included five subjects who were clinically diagnosed with myopericarditis, 30 subjects with asymptomatic elevation of troponins, and 31 subjects with systemic symptoms following immunization, and 34 subjects with no AEFI, serving as controls. Two-hundred pre- and post-smallpox vaccination sera were analyzed by untargeted metabolomics using 1H nuclear magnetic resonance (NMR) spectroscopy. Baseline (pre-) and post-vaccination samples from individuals who experienced clinically verified myocarditis or asymptomatic elevation of troponins were more metabolically distinguishable pre- and post-vaccination compared to individuals who only experienced systemic symptoms, or controls. Metabolomics profiles pre- and post-receipt of vaccine differed substantially when an AEFI resulted. This study is the first to describe pre- and post-vaccination metabolic profiles of subjects who developed an adverse event following immunization. The study demonstrates the promise of metabolites for determining mechanisms associated with subjects who develop AEFI and the potential to develop predictive biomarkers.

Sex-based differences in prevalence and clinical presentation among pericarditis and myopericarditis patients.

BACKGROUND: Sex differences in heart diseases, including acute coronary syndrome, congestive heart failure, and atrial fibrillation, have been studied extensively. However, data are lacking regarding sex differences in pericarditis and myopericarditis patients. OBJECTIVES: The purpose of the study was to evaluate whether there are sex differences in pericarditis and myopericarditis patients as well. METHODS: We performed a retrospective, single-center observational study that included 200 consecutive patients hospitalized with idiopathic pericarditis or myopericarditis from January 2012 to April 2014. Patients were evaluated for sex differences in prevalence, clinical presentation, laboratory variables, and outcome. We excluded patients with a known cause for pericarditis. RESULTS: Among 200 consecutive patients, 55 (27%) were female. Compared with men, women were significantly older (60±19 years vs 46±19 years, P<.001) and had a higher rate of chronic medical conditions. Myopericarditis was significantly more common among men (51% vs 25%, P=.001). Accordingly, men had significantly higher levels of peak troponin (6.8±17 ng/mL vs 0.9±2.6 ng/mL, P<.001), whereas women presented more frequently with pericardial effusion (68% vs 45%, P=.006). Interestingly, women had a significantly lower rate of hospitalization in the cardiology department (42% vs 63%, P=.015). Overall, there were no significant differences in ejection fraction, type of treatment, complications, or in-hospital mortality. CONCLUSIONS: Most patients admitted with acute idiopathic pericarditis are male. In addition, men have a higher prevalence of myocardial involvement. Significant sex differences exist in laboratory variables and in hospital management; however, the outcome is similar and favorable in both sexes.

Pericarditis mimicking Brugada syndrome.

INTRODUCTION: Brugada syndrome (BrS) is a genetic heart disorder due to alteration of the ion channels function that causes an impaired in the cardiac conduction system. It is characterized by an abnormal electrocardiogram pattern and may be complicated by malignant ventricular arrhythmias. Pericarditis is an inflammation of the pericardium and 90% of isolated cases of acute pericarditis are idiopathic or viral. Acute pericarditis may appears with chest pain, fever, pericardial friction rub, and cardiac tamponade. Moreover, widespread ST segment changes occur due to involvement of the underlying epicardium. CASE REPORT: A 27-year-old man was admitted to the Emergency Department of the …. Hospital due to fatigue and chest discomfort. Laboratory findings showed that WBC count and C-reactive protein were increased. Echocardiographic finding was normal. The patient was admitted with a diagnosis of pericarditis. Electrocardiogram (ECG) showed a "saddle back"-type ST elevation in leads V2, recognised as type 2 Brugada pattern. The ECG normalized within a few days after the beginning of anti-inflammatory therapy and the follow-up was uneventful. Based on findings in our patient and data from literature, we hypothesize that the patient developed a Brugada ECG pattern due the pericarditis. CONCLUSIONS: Our case report shows that the pericarditis may mimic BrS. Moreover, it is important to underline that a Brugada ECG pattern should only be considered as a sign of electrical heart disease but detailed diagnostic tests are anyway needed.

Campylobacter jejuni-associated perimyocarditis: two case reports and review of the literature.

BACKGROUND: Campylobacter spp. are among the most common bacterial causes of gastroenteritis world-wide and mostly follow a benign course. We report two cases of Campylobacter jejuni-associated perimyocarditis, the first two simultaneous cases published to date and the third and fourth cases over all in Sweden, and a review of the literature. CASE PRESENTATION: A previously healthy 24-yo male (A) presented at the Emergency Department(ED) with recent onset of chest pain and a 3-day history of abdominal pain, fever and diarrhoea. The symptoms began within a few hours of returning from a tourist visit to a central European capital. Vital signs were stable, the Electrocardiogram(ECG) showed generalized ST-elevation, laboratory testing showed increased levels of C-reactive protein(CRP) and high-sensitive Troponin T(hsTnT). Transthoracic echocardiogram (TTE) was normal, stool cultures were positive for C Jejuni and blood cultures were negative. Two days after patient A was admitted to the ED his travel companion (B), also a previously healthy male (23-yo), presented at the same ED with almost identical symptoms: chest pain precipitated by a few days of abdominal pain, fever and diarrhoea. Patient B declared that he and patient A had ingested chicken prior to returning from their tourist trip. Laboratory tests showed elevated CRP and hsTnT but the ECG and TTE were normal. In both cases, the diagnosis of C jejuni-associated perimyocarditis was set based on the typical presentation and positive stool cultures with identical strains. Both patients were given antibiotics, rapidly improved and were fully recovered at 6-week follow up. CONCLUSION: Perimyocarditis is a rare complication of C jejuni infections but should not be overlooked considering the risk of heart failure. With treatment, the prognosis of full recovery is good but several questions remain to be answered regarding the pathophysiology and the male preponderance of the condition.

Localised pericardial effusion mimicking anterior myocardial infarction following coronary angiography.

The diagnosis of pericarditis is important, especially in patients assumed to have acute coronary syndrome. Distinguishing these two conditions is vital but not always easy. Accurate diagnosis is essential to provide appropriate treatment as soon as possible and to avoid inappropriate invasive procedures. By highlighting this distinction, we report a case of pericarditis that occurred after percutaneous coronary intervention and mimicked acute coronary syndrome.