Heart Failure Reviews

, Volume 18, Issue 3, pp 255–266 | Cite as

Pericardial syndromes: an update after the ESC guidelines 2004

  • Petar M. Seferović
  • Arsen D. Ristić
  • Ružica Maksimović
  • Dejan S. Simeunović
  • Ivan Milinković
  • Jelena P. Seferović Mitrović
  • Vladimir Kanjuh
  • Sabine Pankuweit
  • Bernhard Maisch


Despite a myriad of causes, pericardial diseases present in few clinical syndromes. Acute pericarditis should be differentiated from aortic dissection, myocardial infarction, pneumonia/pleuritis, pulmonary embolism, pneumothorax, costochondritis, gastroesophageal reflux/neoplasm, and herpes zoster. High-risk features indicating hospitalization are: fever >38 °C, subacute onset, large effusion/tamponade, failure of non-steroidal anti-inflammatory drugs (NSAIDs), previous immunosuppression, trauma, anticoagulation, neoplasm, and myopericarditis. Treatment comprises 10–14-days NSAID plus 3 months colchicine (2 × 0.5 mg; 1 × 0.5 mg in patients <70 kg). Corticosteroids are avoided, except for autoimmunity, as they facilitate the recurrences. Echo-guided pericardiocentesis (±fluoroscopy) is indicated for tamponade and effusions >2 cm. Smaller effusions are drained if neoplastic, purulent or tuberculous etiology is suspected. In recurrent pericarditis, repeated testing for autoimmune and thyroid disease is appropriate. Pericardioscopy and pericardial/epicardial biopsy may clarify the etiology. Familial clustering was recently associated with tumor necrosis factor receptor-associated periodic syndrome (TNFRSF1A gene mutation). Treatment includes 10–14 days NSAIDs with colchicine 0.5 mg bid for up to 6 months. In non-responders, low-dose steroids, intrapericardial steroids, azathioprine, and cyclophosphamide can be tried. Successful management with interleukin-1 receptor antagonist (anakinra) was recently reported. Pericardiectomy remains the last option in >2 years severely symptomatic patients. In constriction, expansion of the heart is impaired by the rigid, chronically inflamed/thickened pericardium (no thickening ~20 %). Chest radiography, echocardiography, computerized tomography, magnetic resonance imaging, hemodynamics, and endomyocardial biopsy indicate the diagnosis. Pericardiectomy is the only treatment for permanent constriction. Predictors of poor survival are prior radiation, renal dysfunction, high pulmonary artery pressures, poor left ventricular function, hyponatremia, age, and simultaneous HIV and tuberculous infection.


Pericardial syndromes Acute pericarditis Pericardial effusion Cardiac tamponade Recurrent pericarditis Constrictive pericarditis 


Conflict of interest



  1. 1.
    Maisch B, Seferovic PM, Ristic AD et al (2004) Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Guidelines on the diagnosis and management of pericardial diseases. Executive summary. Eur Heart J 25:587–610CrossRefPubMedGoogle Scholar
  2. 2.
    Lange RA, Hillis LD (2004) Clinical practice. Acute pericarditis. N Engl J Med 351:2195–2202CrossRefPubMedGoogle Scholar
  3. 3.
    Imazio M, Trinchero R (2008) Myopericarditis: etiology, management, and prognosis. Int J Cardiol 127:17–26CrossRefPubMedGoogle Scholar
  4. 4.
    Spodick DH (2001) Pericardial diseases. In: Braunwald E, Zipes D, Libby P (eds) Heart disease: a textbook of cardiovascular medicine, 6th edn. WB Saunders, Philadelphia, pp 1823–1876Google Scholar
  5. 5.
    Ariyarajah V, Spodick DH (2007) Acute pericarditis: diagnostic cues and common electrocardiographic manifestations. Cardiol Rev 15:24–30CrossRefPubMedGoogle Scholar
  6. 6.
    Yared K, Baggish AL, Picard MH et al (2010) Multimodality imaging of pericardial diseases. JACC Cardiovasc Imaging 3:650–660CrossRefPubMedGoogle Scholar
  7. 7.
    Imazio M, Brucato A, Doria A et al (2009) Antinuclear antibodies in recurrent idiopathic pericarditis: prevalence and clinical significance. Int J Cardiol 136:289–293CrossRefPubMedGoogle Scholar
  8. 8.
    Dudzinski DM, Mak GS, Hung JW (2012) Pericardial diseases. Curr Probl Cardiol 37:75–118CrossRefPubMedGoogle Scholar
  9. 9.
    Imazio M, Cecchi E, Demichelis B et al (2007) Indicators of poor prognosis of acute pericarditis. Circulation 115:2739–2744CrossRefPubMedGoogle Scholar
  10. 10.
    Imazio M, Demichelis B, Parrini I et al (2004) Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol 43:1042–1046CrossRefPubMedGoogle Scholar
  11. 11.
    Lotrionte M, Biondi-Zoccai G, Imazio M et al (2010) International collaborative systematic review of controlled clinical trials on pharmacologic treatments for acute pericarditis and its recurrences. Am Heart J 160:662–670CrossRefPubMedGoogle Scholar
  12. 12.
    Imazio M, Adler Y (2012) Treatment with aspirin, NSAID, corticosteroids, and colchicine in acute and recurrent pericarditis. Heart Fail Rev [Epub ahead of print]Google Scholar
  13. 13.
    Imazio M, Bobbio M, Cecchi E et al (2005) Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation 112:2012–2016CrossRefPubMedGoogle Scholar
  14. 14.
    Artom G, Koren-Morag N, Spodick DH et al (2005) Pretreatment with corticosteroids attenuates the efficacy of colchicine in preventing recurrent pericarditis: a multi-centre all-case analysis. Eur Heart J 26:723–727CrossRefPubMedGoogle Scholar
  15. 15.
    Maisch B, Ristić AD, Seferović PM, Tsang TSM (2011) Interventional pericardiology: pericardiocentesis, pericardioscopy, pericardial biopsy, balloon pericardiotomy, and intrapericardial therapy. Springer, HeidelbergCrossRefGoogle Scholar
  16. 16.
    Brucato A, Maestroni S, Cumetti D et al (2008) Recurrent pericarditis: infectious or autoimmune? Autoimmun Rev 8:44–47CrossRefPubMedGoogle Scholar
  17. 17.
    Caforio AL, Brucato A, Doria A et al (2010) Anti-heart and anti-intercalated disk autoantibodies: evidence for autoimmunity in idiopathic recurrent acute pericarditis. Heart 96:779–784CrossRefPubMedGoogle Scholar
  18. 18.
    Cantarini L, Lucherini OM, Baldari CT et al (2010) Familial clustering of recurrent pericarditis may disclose tumour necrosis factor receptor-associated periodic syndrome. Clin Exp Rheumatol 28:405–407PubMedGoogle Scholar
  19. 19.
    Cantarini L, Lucherini OM, Cimaz R, Galeazzi M (2010) Recurrent pericarditis caused by a rare mutation in the TNFRSF1A gene and with excellent response to anakinra treatment. Clin Exp Rheumatol 28:802PubMedGoogle Scholar
  20. 20.
    Imazio M, Brucato A, Cemin R et al (2011) CORP (COlchicine for Recurrent Pericarditis) Investigators. Colchicine for recurrent pericarditis (CORP): a randomized trial. Ann Intern Med 155:409–414PubMedGoogle Scholar
  21. 21.
    Imazio M, Brucato A, Cumetti D et al (2008) Corticosteroids for recurrent pericarditis: high versus low doses: a nonrandomized observation. Circulation 118:667–671CrossRefPubMedGoogle Scholar
  22. 22.
    Maisch B, Ristić AD, Pankuweit S (2002) Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone; the way to avoid side effects of systemic corticosteroid therapy. Eur Heart J 23:1503–1508CrossRefPubMedGoogle Scholar
  23. 23.
    Vianello F, Cinetto F, Cavraro M et al (2011) Azathioprine in isolated recurrent pericarditis: a single centre experience. Int J Cardiol 147:477–478CrossRefPubMedGoogle Scholar
  24. 24.
    Vassilopoulos D, Lazaros G, Tsioufis C et al (2012) Successful treatment of adult patients with idiopathic recurrent pericarditis with an interleukin-1 receptor antagonist (anakinra). Int J Cardiol [Epub ahead of print]Google Scholar
  25. 25.
    George TJ, Arnaoutakis GJ, Beaty CA et al (2012) Contemporary etiologies, risk factors, and outcomes after pericardiectomy. Ann Thorac Surg [Epub ahead of print]Google Scholar
  26. 26.
    Sagrista-Sauleda J, Merce J, Permanyer-Miralda G, Soler–Soler J (2000) Clinical clues to the causes of large pericardial effusions. Am J Med 109:95–101CrossRefPubMedGoogle Scholar
  27. 27.
    Spodick DH (2003) Acute cardiac tamponade. N Engl J Med 349:684–690CrossRefPubMedGoogle Scholar
  28. 28.
    Spodick DH (1997) Physiology of cardiac tamponade. In: Spodick DH (ed) The pericardium: a comprehensive textbook. Marcel Dekker, New York, pp 180–190Google Scholar
  29. 29.
    Schairer JR, Biswas S, Keteyian SJ, Ananthasubramaniam K (2011) A systematic approach to evaluation of pericardial effusion and cardiac tamponade. Cardiol Rev 19:233–238CrossRefPubMedGoogle Scholar
  30. 30.
    Delgado C, Barturen F (1999) Atrial tamponade causing acute ischemic hepatic injury after cardiac surgery. Clin Cardiol 22:242–244CrossRefPubMedGoogle Scholar
  31. 31.
    Ramsaran EK, Benotti JR, Spodick DH (1995) Exacerbated tamponade: deterioration of cardiac function by lowering excessive arterial pressure in hypertensive cardiac tamponade. Cardiology 86:77–79CrossRefPubMedGoogle Scholar
  32. 32.
    Siniorakis E, Arvanitakis S, Hardavella G et al (2010) Searching for pulsus paradoxus and correlates in cardiac tamponade. Int J Cardiol 145:127–128CrossRefPubMedGoogle Scholar
  33. 33.
    Ntsekhe M, Shey Wiysonge C, Commerford PJ, Mayosi BM (2012) The prevalence and outcome of effusive constrictive pericarditis: a systematic review of the literature. Cardiovasc J Afr 22:1–5Google Scholar
  34. 34.
    Oliver C, Marin F, Pineda J et al (2002) Low QRS voltage in cardiac tamponade: a study of 70 cases. Int J Cardiol 83:91–92CrossRefPubMedGoogle Scholar
  35. 35.
    Ristić AD, Wagner HJ, Maksimović R, Maisch B (2012) Epicardial halo phenomenon: a guide for pericardiocentesis? Heart Fail Rev [Epub ahead of print]Google Scholar
  36. 36.
    Bodson L, Bouferrache K, Vieillard-Baron A (2011) Cardiac tamponade. Curr Opin Crit Care 17:416–424CrossRefPubMedGoogle Scholar
  37. 37.
    Merce J, Sagrista-Sauleda J, Permanyer-Miralda G et al (1999) Correlation between clinical and Doppler echocardiographic findings in patients with moderate and large pericardial effusion: implications for the diagnosis of cardiac tamponade. Am Heart J 138:759–764CrossRefPubMedGoogle Scholar
  38. 38.
    Roy CL, Minor MA, Brookhart MA, Choudhry NK (2007) Does this patient with a pericardial effusion have cardiac tamponade? JAMA 297(16):1810–1818CrossRefPubMedGoogle Scholar
  39. 39.
    Togni M, Shabetai R, Blanchard D (2001) Color M-mode Doppler flow propagation velocity in cardiac tamponade. J Am Coll Cardiol 37(1):328–329CrossRefPubMedGoogle Scholar
  40. 40.
    Nishikawa Y, Roberts JP, Talcott MR, Dysko RC, Tan P, Klopfenstein HS (1994) Accelerated myocardial relaxation in conscious dogs during acute cardiac tamponade. Am J Phys 266(5 Pt 2):H1935–H1943Google Scholar
  41. 41.
    Singh S, Wann LS, Schuchard GH et al (1984) Right ventricular and right atrial collapse in patients with cardiac tamponade—a combined echocardiographic and hemodynamic study. Circulation 70:966–971CrossRefPubMedGoogle Scholar
  42. 42.
    Spodick DH (1989) Low atrial natriuretic factor levels and absent pulmonary edema in pericardial compression of the heart. Am J Cardiol 63:1271–1272CrossRefPubMedGoogle Scholar
  43. 43.
    Shabetai R, Fowler NO, Guntheroth WG (1970) The hemodynamics of cardiac tamponade and constrictive pericarditis. Am J Cardiol 26:480–489CrossRefPubMedGoogle Scholar
  44. 44.
    Sagrista-Sauleda J, Angel J, Sanchez A et al (2004) Effusive-constrictive pericarditis. N Engl J Med 350:469–475CrossRefPubMedGoogle Scholar
  45. 45.
    Gascho JA, Martins JB, Marcus ML, Kerber RE (1981) Effects of volume expansion and vasodilators in acute pericardial tamponade. Am J Physiol 240:H49–H53PubMedGoogle Scholar
  46. 46.
    Spodick DH (1991) Medical treatment of cardiac tamponade. In: Caturelli G (ed) Cura intensiva cardiologica. TIPAR Poligrafica, Rome, pp 265–268Google Scholar
  47. 47.
    Hashim R, Frankel H, Tandon M, Rabinovici R (2002) Fluid resuscitation-induced cardiac tamponade. Trauma 53:1183–1184CrossRefGoogle Scholar
  48. 48.
    Grocott HP, Gulati H, Srinathan S, Mackensen GB (2011) Anesthesia and the patient with pericardial disease. Can J Anaesth 58(10):952–966CrossRefPubMedGoogle Scholar
  49. 49.
    Talreja DR, Edwards WD, Danielson GK et al (2003) Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation 108:1852–1857CrossRefPubMedGoogle Scholar
  50. 50.
    Haley JH, Tajik AJ, Danielson GK, Schaff HV, Mulvagh SL, Oh JK (2004) Transient constrictive pericarditis: causes and natural history. J Am Coll Cardiol 43(2):271–275CrossRefPubMedGoogle Scholar
  51. 51.
    Byrne JG, Karavas AN, Colson YL et al (2002) Cardiac decortication (epicardiectomy) for occult constrictive cardiac physiology after left extrapleural pneumonectomy. Chest 122(6):2256–2259CrossRefPubMedGoogle Scholar
  52. 52.
    Föll D, Geibel-Zehender A, Bode C (2010) Constrictive pericarditis: etiology, diagnostic work-up, and therapy. Herz 35(2):80–85CrossRefPubMedGoogle Scholar
  53. 53.
    Imazio M, Brucato A, Maestroni S et al (2011) Risk of constrictive pericarditis after acute pericarditis. Circulation 124:1270–1275CrossRefPubMedGoogle Scholar
  54. 54.
    Suwan PK, Potjalongsilp S (1995) Predictors of constrictive pericarditis after tuberculous pericarditis. Br Heart J 73:187–189CrossRefPubMedGoogle Scholar
  55. 55.
    Komsuoglu B, Goldeli O, Kulan K, Komsuoglu SS (1995) The diagnostic and prognostic value of adenosine deaminase in tuberculous pericarditis. Eur Heart J 16:1126–1130PubMedGoogle Scholar
  56. 56.
    Ntsekhe M, Mayosi BM (2012) Tuberculous pericarditis with and without HIV. Heart Fail Rev Mar 18 [Epub ahead of print]Google Scholar
  57. 57.
    Shabetai R (2003) The pericardium. Kluwer Academic Publishers, BostonGoogle Scholar
  58. 58.
    Schwefer M, Aschenbach R, Heidemann J, Mey C, Lapp H (2009) Constrictive pericarditis, still a diagnostic challenge: comprehensive review of clinical management. Eur J Cardiothorac Surg 36:502–510CrossRefPubMedGoogle Scholar
  59. 59.
    Leya FS, Arab D, Joyal D et al (2005) The efficacy of brain natriuretic peptide levels in differentiating constrictive pericarditis from restrictive cardiomyopathy. J Am Coll Cardiol 45(11):1900–1902CrossRefPubMedGoogle Scholar
  60. 60.
    Kapoor PM, Aggarwal V, Chowdhury U, Choudhury M, Singh SP, Kiran U (2010) Comparison of B-type natriuretic peptide and left ventricular dysfunction in patients with constrictive pericarditis undergoing pericardiectomy. Ann Card Anaesth 13(2):123–129CrossRefPubMedGoogle Scholar
  61. 61.
    Spodick DH (1997) Constrictive pericarditis. In: Spodick DH (ed) The pericardium: a comprehensive textbook. Marcel Dekker, New York, pp 214–259Google Scholar
  62. 62.
    Oh JK, Tajik AJ, Seward JB et al (1994) Diagnostic role of Doppler echocardiography in constrictive pericarditis. J Am Coll Cardiol 23:154–162CrossRefPubMedGoogle Scholar
  63. 63.
    Sengupta PP, Mohan JC, Mehta V, Arora R, Pandian NG, Khandheria BK (2004) Accuracy and pitfalls of early diastolic motion of the mitral annulus for diagnosing constrictive pericarditis by tissue Doppler imaging. Am J Cardiol 93(7):886–890CrossRefPubMedGoogle Scholar
  64. 64.
    Ha JW, Ommen SR, Tajik AJ et al (2004) Differentiation of constrictive pericarditis from restrictive cardiomyopathy using mitral annular velocity by tissue Doppler echocardiography. Am J Cardiol 94(3):316–319CrossRefPubMedGoogle Scholar
  65. 65.
    Choi JH, Choi JO, Ryu DR et al (2011) Mitral and tricuspid annular velocities in constrictive pericarditis and restrictive cardiomyopathy: correlation with pericardial thickness on computed tomography. JACC Cardiovasc Imaging 4(6):567–575CrossRefPubMedGoogle Scholar
  66. 66.
    Rienmuller R, Gurgan M, Erdmann E et al (1993) CT and MR evaluation of pericardial constriction: a new diagnostic and therapeutic concept. J Thorac Imaging 8(2):108–121CrossRefGoogle Scholar
  67. 67.
    Feng D, Glockner J, Kim K et al (2011) Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy: a pilot study. Circulation 124(17):1830–1837CrossRefPubMedGoogle Scholar
  68. 68.
    Zagol B, Minderman D, Munir A, D’Cruz I (2007) Effusive constrictive pericarditis: 2D, 3D echocardiography and MRI imaging. Echocardiography 24:1110–1114CrossRefPubMedGoogle Scholar
  69. 69.
    Zurick AO, Bolen MA, Kwon DH et al (2011) Pericardial delayed hyperenhancement with CMR imaging in patients with constrictive pericarditis undergoing surgical pericardiectomy: a case series with histopathological correlation. JACC Cardiovasc Imaging 4:1180–1191CrossRefPubMedGoogle Scholar
  70. 70.
    Talreja DR, Nishimura RA, Oh JK, Holmes DR (2008) Constrictive pericarditis in the modern era: novel criteria for diagnosis in the cardiac catheterization laboratory. J Am Coll Cardiol 51(3):315–319CrossRefPubMedGoogle Scholar
  71. 71.
    Sagrista-Sauleda J (2004) Pericardial constriction: uncommon patterns. Heart 90(3):257–258CrossRefPubMedGoogle Scholar
  72. 72.
    Tyberg TI, Goodyer AVN, Hurst VW et al (1981) Left ventricular filling in differentiating restrictive amyloid cardiomyopathy and constrictive pericarditis. Am J Cardiol 47:791–795CrossRefPubMedGoogle Scholar
  73. 73.
    Boonyaratavej S, Oh JK, Tajik AJ et al (1998) Comparison of mitral inflow and superior vena cava Doppler velocities in chronic obstructive pulmonary disease and constrictive pericarditis. J Am Coll Cardiol 32(7):2043–2048CrossRefPubMedGoogle Scholar
  74. 74.
    Rajagopalan N, Garcia MJ, Rodriguez L et al (2001) Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol 87(1):86–94CrossRefPubMedGoogle Scholar
  75. 75.
    Ristić AD (2004) Hot topic: constrictive pericarditis: who, when, and how should be treated? Herz 29(2):220–222CrossRefGoogle Scholar
  76. 76.
    Ling LH, Oh JK, Schaff HV et al (1999) Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation 100(13):1380–1386CrossRefPubMedGoogle Scholar
  77. 77.
    Senni M, Redfield MM, Ling LH et al (1999) Left ventricular systolic and diastolic function after pericardiectomy in patients with constrictive pericarditis: Doppler echocardiographic findings and correlation with clinical status. J Am Coll Cardiol 33(5):1182–1188CrossRefPubMedGoogle Scholar
  78. 78.
    Bertog SC, Thambidorai SK, Parakh K et al (2004) Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy. J Am Coll Cardiol 43(8):1445–1452CrossRefPubMedGoogle Scholar
  79. 79.
    Yamamoto N, Ohara K, Nie M, Torii S, Inoue N, Miyaji K (2011) For what type of constrictive pericarditis is the waffle procedure effective? Asian Cardiovasc Thorac Ann 19(2):115–118PubMedGoogle Scholar
  80. 80.
    Veress G, Ling LH, Kim KH et al (2011) Mitral and tricuspid annular velocities before and after pericardiectomy in patients with constrictive pericarditis. Circ Cardiovasc Imaging 4(4):399–407CrossRefPubMedGoogle Scholar
  81. 81.
    Strang JI, Nunn AJ, Johnson DA, Casbard A, Gibson DG, Girling DJ (2004) Management of tuberculous constrictive pericarditis and tuberculous pericardial effusion in Transkei: results at 10 years follow-up. QJM 97(8):525–535CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Petar M. Seferović
    • 1
  • Arsen D. Ristić
    • 1
  • Ružica Maksimović
    • 2
  • Dejan S. Simeunović
    • 1
  • Ivan Milinković
    • 1
  • Jelena P. Seferović Mitrović
    • 1
  • Vladimir Kanjuh
    • 1
  • Sabine Pankuweit
    • 3
  • Bernhard Maisch
    • 3
  1. 1.Department of CardiologyClinical Center of Serbia and Belgrade University School of MedicineBelgradeSerbia
  2. 2.Department of RadiologyClinical Center of Serbia and Belgrade University School of MedicineBelgradeSerbia
  3. 3.Department of Internal Medicine-Cardiology, Faculty of MedicinePhilipps UniversityMarburgGermany

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