Colchicina administrada en el primer episodio de pericarditis aguda idiopática: estudio multicéntrico abierto y aleatorizado / Colchicine administered in the first episode of acute idiopathic pericarditis: a randomized multicenter open-label study

Introducción y objetivos: Se dispone de poca información sobre el beneficio real de la administración de colchicina en el primer episodio de pericarditis aguda idiopática (PAI). El objetivo principal del presente estudio es evaluar la eficacia real de la colchicina en pacientes con PAI que no toman corticoides. Métodos: Estudio multicéntrico abierto y aleatorizado. Se aleatorizó en 2 grupos a los pacientes con un primer episodio de PAI (no secundario a lesión cardiaca o enfermedad del tejido conectivo): A, con tratamiento antiinflamatorio convencional más colchicina durante 3 meses, y B, con tratamiento antiinflamatorio convencional solamente. Ningún paciente tomaba corticoides. El objetivo primario del estudio fue la aparición de episodios recurrentes de pericarditis. El objetivo secundario fue el tiempo hasta la primera recurrencia. El seguimiento fue de 24 meses. Resultados: Se aleatorizó a 110 pacientes (el 83,6% varones; media de edad, 44+/-18,3 años) a los grupos A (59 pacientes) y B (51 pacientes). No se encontraron diferencias entre ambos grupos en las características basales, las características clínicas del episodio índice o el tipo de tratamiento antiinflamatorio administrado. Completaron el seguimiento 102 pacientes (92,7%). No se encontraron diferencias entre los grupos en la tasa de pericarditis recurrente (12 pacientes [10,9%]; grupo A frente a grupo B, el 13,5 frente al 7,8%; p=0,34). El tiempo hasta la primera recurrencia (9,6+/-9.0 frente a 8,3+/-10,5 meses; p=0,80) no fue diferente entre los grupos. Conclusiones: En pacientes con un primer episodio de PAI que no habían tomado corticoides, no parece que la adición de colchicina al tratamiento antiinflamatorio convencional reduzca la tasa de recurrencias. Registro de ensayos clínicos: URL: https://www.clinicaltrialsregister.eu. Identificador: EudraCT 2009-011258-16

Introduction and objectives: There is a paucity of information about the real benefit of colchicine administration in the first episode of acute idiopathic pericarditis (AIP). The main objective of the present study was to assess the real efficacy of colchicine in patients with AIP who did not receive corticosteroids. Methods: Randomized multicenter open-label study. Patients with a first episode of AIP (not secondary to cardiac injury or connective tissue disease) were randomized into 2 groups: group A received conventional anti-inflammatory treatment plus colchicine for 3 months, and group B received conventional anti-inflammatory treatment only. None of the patients received corticosteroids. The primary endpoint was the appearance of recurrent episodes of pericarditis. The secondary endpoint was the time to first recurrence. Follow-up was extended to 24 months. Results: A total of 110 patients (83.6% men, age 44+/-18.3 years) were randomized to group A (n=59) and group B (n=51). No differences were found in baseline demographics or in the clinical features of the index episode or in the type of anti-inflammatory treatment administered in both groups. The follow-up was completed by 102 patients (92.7%). No differences were found in the rate of recurrent pericarditis between groups (12 patients [10.9%]; group A vs group B, 13.5% vs 7.8%; P=.34). The time to first recurrence (group A vs group B, 9.6+/-9.0 vs 8.3+/-10.5 months; P=.80) did not differ between groups. Conclusions: Among patients with a first episode of AIP who had not received corticosteroids, the addition of colchicine to conventional anti-inflammatory treatment does not seem to reduce the recurrence rate. Clinical trial registration: URL: https://www.clinicaltrialsregister.eu. Identifier: EudraCT 2009-011258-16

Colchicine Administered in the First Episode of Acute Idiopathic Pericarditis: A Randomized Multicenter Open-label Study.

INTRODUCTION AND OBJECTIVES: There is a paucity of information about the real benefit of colchicine administration in the first episode of acute idiopathic pericarditis (AIP). The main objective of the present study was to assess the real efficacy of colchicine in patients with AIP who did not receive corticosteroids. METHODS: Randomized multicenter open-label study. Patients with a first episode of AIP (not secondary to cardiac injury or connective tissue disease) were randomized into 2 groups: group A received conventional anti-inflammatory treatment plus colchicine for 3 months, and group B received conventional anti-inflammatory treatment only. None of the patients received corticosteroids. The primary endpoint was the appearance of recurrent episodes of pericarditis. The secondary endpoint was the time to first recurrence. Follow-up was extended to 24 months. RESULTS: A total of 110 patients (83.6% men, age 44±18.3 years) were randomized to group A (n=59) and group B (n=51). No differences were found in baseline demographics or in the clinical features of the index episode or in the type of anti-inflammatory treatment administered in both groups. The follow-up was completed by 102 patients (92.7%). No differences were found in the rate of recurrent pericarditis between groups (12 patients [10.9%]; group A vs group B, 13.5% vs 7.8%; P=.34). The time to first recurrence (group A vs group B, 9.6±9.0 vs 8.3±10.5 months; P=.80) did not differ between groups. CONCLUSIONS: Among patients with a first episode of AIP who had not received corticosteroids, the addition of colchicine to conventional anti-inflammatory treatment does not seem to reduce the recurrence rate. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrialsregister.eu. Identifier: EudraCT 2009-011258-16.

Pericarditis constrictiva: espectro etiológico, presentaciones clínicas, factores pronósticos y seguimiento a largo plazo / Constrictive pericarditis: etiologic spectrum, patterns of clinical presentation, prognostic factors, and long-term follow-up

Introducción y objetivos: Algunos estudios han descrito un cambio en el espectro etiológico de la pericarditis constrictiva. Además, no hay datos sobre la relación entre la forma de presentación clínica y la etiología. El objetivo de este estudio es describir las etiologías de la enfermedad, su relación con la forma de presentación clínica y los hallazgos quirúrgicos, así como identificar los factores predictivos de una mala evolución. Métodos: Se analizó a un total de 140 pacientes consecutivos a los que se practicaron intervenciones quirúrgicas por pericarditis constrictiva en un mismo centro en un periodo de 34 años. Resultados: La etiología fue idiopática en 76 pacientes (54%) y tras pericarditis aguda idiopática en 24 (17%), pericarditis tuberculosa en 15 (11%), pericarditis purulenta en 10 (7%) y cirugía cardiaca en 5 (4%), radioterapia en 3 (2%) y uremia en 2 (1%). La duración media de los síntomas antes de la pericardiectomía fue de 19 meses (desviación estándar: 44 meses); la forma de presentación clínica más aguda fue la de las pericarditis purulentas (26 [intervalo, 7-60] días) y la más crónica, la de los casos idiopáticos (29 meses [4 días-360 meses]). La mortalidad perioperatoria fue del 11%. No hubo diferencias en la mortalidad según etiologías. La mediana de seguimiento fue de 12 (0,1-33,0) años, durante los cuales fallecieron 50 pacientes. En un análisis de regresión de Cox, la edad en el momento de la operación, la clase funcional de la New York Heart Association avanzada (III–IV) y los antecedentes de pericarditis aguda idiopática se asociaron a una mayor mortalidad durante el seguimiento. Conclusiones: La mayoría de los casos de pericarditis constrictiva son idiopáticas. La cirugía cardiaca y la radioterapia causan una minoría de los casos. Las presentaciones aguda y subaguda merecen un estudio etiológico. La edad, la clase funcional avanzada y la pericarditis aguda idiopática previa se asocian a mayor mortalidad (AU)

Introduction and objectives: Some reports have described a change in the etiologic spectrum of constrictive pericarditis. In addition, data on the relationship between its clinical presentation and etiology are lacking. We sought to describe the etiologies of the disease, their relationship with its clinical presentation and surgical findings, and to identify predictors of poor outcome. Methods: We analyzed 140 consecutive patients who underwent surgery for constrictive pericarditis over a 34-year period in a single center. Results: The etiology was idiopathic in 76 patients (54%), acute idiopathic pericarditis in 24 patients (17%), tuberculous pericarditis in 15 patients (11%), purulent pericarditis in 10 patients (7%), and cardiac surgery, radiation and uremia in 5, 3 and 2 patients respectively (4%, 2% and 1%).Mean duration of symptoms before pericardiectomy was 19 months (standard deviation=44 months), the most acute presentation being for purulent pericarditis (26 days [range, 7-60 days]) and the most chronic for idiopathic cases (29 months [range, 4 days-360 months]). Perioperative mortality was 11%. There was no difference in mortality between etiologies. Median follow-up was 12 years (range, 0.1-33.0 years) in which 50 patients died. In a Cox-regressionanalysis, age at surgery, advanced New York HeartAssociation functional class (IIIto IV) and previous acute idiopathic pericarditis were associated with increased mortality during follow-up. Conclusions: Most cases of constrictive pericarditis are idiopathic. Cardiac surgery and radiation accounted for a minority of cases. Etiologic investigations are warranted only in acute or subacute presentations. Age, advanced functional class, and previous acute idiopathic pericarditis are associated with increased mortality (AU)

Constrictive Pericarditis: Etiologic Spectrum, Patterns of Clinical Presentation, Prognostic Factors, and Long-term Follow-up.

INTRODUCTION AND OBJECTIVES: Some reports have described a change in the etiologic spectrum of constrictive pericarditis. In addition, data on the relationship between its clinical presentation and etiology are lacking. We sought to describe the etiologies of the disease, their relationship with its clinical presentation and surgical findings, and to identify predictors of poor outcome. METHODS: We analyzed 140 consecutive patients who underwent surgery for constrictive pericarditis over a 34-year period in a single center. RESULTS: The etiology was idiopathic in 76 patients (54%), acute idiopathic pericarditis in 24 patients (17%), tuberculous pericarditis in 15 patients (11%), purulent pericarditis in 10 patients (7%), and cardiac surgery, radiation and uremia in 5, 3 and 2 patients respectively (4%, 2% and 1%). Mean duration of symptoms before pericardiectomy was 19 months (standard deviation, 44 months), the most acute presentation being for purulent pericarditis (26 days [range, 7-60 days]) and the most chronic for idiopathic cases (29 months [range, 4 days-360 months]). Perioperative mortality was 11%. There was no difference in mortality between etiologies. Median follow-up was 12 years (range, 0.1-33.0 years) in which 50 patients died. In a Cox-regression analysis, age at surgery, advanced New York Heart Association functional class (III to IV) and previous acute idiopathic pericarditis were associated with increased mortality during follow-up. CONCLUSIONS: Most cases of constrictive pericarditis are idiopathic. Cardiac surgery and radiation accounted for a minority of cases. Etiologic investigations are warranted only in acute or subacute presentations. Age, advanced functional class, and previous acute idiopathic pericarditis are associated with increased mortality.

Diagnosis and management of pericardial effusion.

Pericardial effusion is a common finding in everyday clinical practice. The first challenge to the clinician is to try to establish an etiologic diagnosis. Sometimes, the pericardial effusion can be easily related to a known underlying disease, such as acute myocardial infarction, cardiac surgery, end-stage renal disease or widespread metastatic neoplasm. When no obvious cause is apparent, some clinical findings can be useful to establish a diagnosis of probability. The presence of acute inflammatory signs (chest pain, fever, pericardial friction rub) is predictive for acute idiopathic pericarditis irrespective of the size of the effusion or the presence or absence of tamponade. Severe effusion with absence of inflammatory signs and absence of tamponade is predictive for chronic idiopathic pericardial effusion, and tamponade without inflammatory signs for neoplastic pericardial effusion. Epidemiologic considerations are very important, as in developed countries acute idiopathic pericarditis and idiopathic pericardial effusion are the most common etiologies, but in some underdeveloped geographic areas tuberculous pericarditis is the leading cause of pericardial effusion. The second point is the evaluation of the hemodynamic compromise caused by pericardial fluid. Cardiac tamponade is not an "all or none" phenomenon, but a syndrome with a continuum of severity ranging from an asymptomatic elevation of intrapericardial pressure detectable only through hemodynamic methods to a clinical tamponade recognized by the presence of dyspnea, tachycardia, jugular venous distension, pulsus paradoxus and in the more severe cases arterial hypotension and shock. In the middle, echocardiographic tamponade is recognized by the presence of cardiac chamber collapses and characteristic alterations in respiratory variations of mitral and tricuspid flow. Medical treatment of pericardial effusion is mainly dictated by the presence of inflammatory signs and by the underlying disease if present. Pericardial drainage is mandatory when clinical tamponade is present. In the absence of clinical tamponade, examination of the pericardial fluid is indicated when there is a clinical suspicion of purulent pericarditis and in patients with underlying neoplasia. Patients with chronic massive idiopathic pericardial effusion should also be submitted to pericardial drainage because of the risk of developing unexpected tamponade. The selection of the pericardial drainage procedure depends on the etiology of the effusion. Simple pericardiocentesis is usually sufficient in patients with acute idiopathic or viral pericarditis. Purulent pericarditis should be drained surgically, usually through subxiphoid pericardiotomy. Neoplastic pericardial effusion constitutes a more difficult challenge because reaccumulation of pericardial fluid is a concern. The therapeutic possibilities include extended indwelling pericardial catheter, percutaneous pericardiostomy and intrapericardial instillation of antineoplastic and sclerosing agents. Massive chronic idiopathic pericardial effusions do not respond to medical treatment and tend to recur after pericardiocentesis, so wide anterior pericardiectomy is finally necessary in many cases.

[Cardiac constriction syndromes]. / Síndromes de constricción cardiaca.

This article focuses on syndromes associated with cardiac constriction (i.e., constrictive pericarditis). These include classic chronic constrictive pericarditis, subacute <> constriction including effusive-constrictive pericarditis, transient cardiac constriction, and occult constrictive pericarditis, all of which have their own clinical and developmental peculiarities. Establishing clinical suspicion is the basic first step in making a diagnosis, which can subsequently be confirmed by careful interpretation of imaging studies. With pericardial calcification, a simple chest radiograph may be sufficient; in other cases, Doppler echocardiography or chest computed tomography are necessary. The diagnosis of effusive-constrictive pericarditis requires cardiac catheterization combined with pericardiocentesis and the recording of intracavitary and intrapericardial pressures both before and after pericardiocentesis. It should be remembered that spontaneous regression is possible in some forms of constrictive pericarditis, particularly those that appear during the resolution of acute idiopathic pericarditis with effusion or that develop after cardiac surgery. Finally, there are only a few reports in the literature about occult constrictive pericarditis and its diagnosis is problematic.

Hemodynamic effects of volume expansion in patients with cardiac tamponade.

BACKGROUND: Volume expansion has been proposed as an alternative treatment for cardiac tamponade; however, the scientific evidence for this recommendation is very poor. METHODS AND RESULTS: Forty-nine unselected patients (23 males; age 55+/-16 years) with large pericardial effusion and hemodynamic tamponade underwent fluid overload with intravenous administration of 500 mL of normal saline over 10 minutes. Cardiac index and intrapericardial, left ventricular end-diastolic, right atrial, and right ventricular end-diastolic pressures were measured during basal state (tamponade), after fluid overload, and after pericardiocentesis. Twenty-eight patients (57%) had physical signs of tamponade, and 10 (20%) were hypotensive. Size of pericardial effusion was 31+/-13 mm. Initial mean arterial pressure was 88+/-21 mm Hg, and cardiac index was 2.46+/-0.80 L x min(-1) x m(-2). Intrapericardial pressure was 8.31+/-5.98 mm Hg. Volume expansion caused a significant increase in mean arterial pressure (from 88+/-21 to 94+/-23 mm Hg, P=0.003) and cardiac index (from 2.46+/-0.80 to 2.64+/-0.68 L x min(-1) x m(-2), P=0.013), as well as in intrapericardial pressure (from 8.31+/-5.98 to 11.02+/-6.27 mm Hg, P=0.0001), right atrial pressure (from 9.76+/-5.91 to 12.82+/-6.34 mm Hg, P=0.0001), and left ventricular end-diastolic pressure (from 14.21+/-5.97 to 19.48+/-6.19 mm Hg, P=0.0001). Cardiac index increased by >10% in 23 patients (47%), remained unchanged in 11 (22%), and decreased in 15 (31%). No patient developed clinical complications. Predictors of this favorable response were systolic blood pressure <100 mm Hg and low cardiac index. CONCLUSIONS: Approximately one half of patients with cardiac tamponade develop a significant increase in cardiac output after volume overload. Low systolic blood pressure (<100 mm Hg) at baseline was the simplest clinical finding that was predictive of this favorable response.

Síndromes de constricción cardiaca / Cardiac Constriction Syndromes

En este artículo se describen los síndromes de pericarditis constrictiva. Estos incluyen la pericarditis constrictiva crónica clásica, la pericarditis constrictiva subaguda elástica, que abarca la pericarditis efusivo-constrictiva, la pericarditis constrictiva transitoria y la pericarditis constrictiva oculta, las cuales tienen peculiaridades clínicas y evolutivas propias. Para su diagnóstico es fundamental, en primer lugar, establecer la sospecha clínica, y luego interpretar de forma adecuada los hallazgos de las técnicas de imagen. Estas pueden consistir en algo tan sencillo como una radiografía de tórax en el caso de una pericarditis crónica calcificada, pero en otros casos se requiere la práctica de un ecocardiograma Doppler o una tomografía computarizada torácica. El diagnóstico de pericarditis efusivo-constrictiva requiere la práctica de un estudio hemodinámico combinado con una pericardiocentesis y con el registro de las presiones intracavitarias e intrapericárdica antes y después de la pericardiocentesis. Se insiste en la posibilidad de que algunas pericarditis constrictivas, especialmente las que aparecen en la fase de resolución de las pericarditis agudas idiopáticas con derrame y en las pericarditis tras cirugía cardiaca, pueden remitir espontáneamente. Por último, comentar que el concepto de pericarditis constrictiva oculta ha sido poco documentado en la literatura y su diagnóstico es poco preciso (AU)

This article focuses on syndromes associated with cardiac constriction (i.e., constrictive pericarditis). These include classic chronic constrictive pericarditis, subacute «elastic» constriction including effusive-constrictive pericarditis, transient cardiac constriction, and occult constrictive pericarditis, all of which have their own clinical and developmental peculiarities. Establishing clinical suspicion is the basic first step in making a diagnosis, which can subsequently be confirmed by careful interpretation of imaging studies. With pericardial calcification, a simple chest radiograph may be sufficient; in other cases, Doppler echocardiography or chest computed tomography are necessary. The diagnosis of effusive-constrictive pericarditis requires cardiac catheterization combined with pericardiocentesis and the recording of intracavitary and intrapericardial pressures both before and after pericardiocentesis. It should be remembered that spontaneous regression is possible in some forms of constrictive pericarditis, particularly those that appear during the resolution of acute idiopathic pericarditis with effusion or that develop after cardiac surgery. Finally, there are only a few reports in the literature about occult constrictive pericarditis and its diagnosis is problematic (AU)

Low-pressure cardiac tamponade: clinical and hemodynamic profile.

BACKGROUND: Low-pressure cardiac tamponade is a form of cardiac tamponade in which a comparatively low pericardial pressure results in cardiac compression because of low filling pressure. This syndrome is poorly characterized because only isolated cases have been reported. We conducted a study of its clinical and hemodynamic profiles. METHODS AND RESULTS: From 1986 through 2004, we evaluated all patients at our institution with combined pericardiocentesis and cardiac catheterization. We identified those patients who fulfilled catheterization-based criteria of low-pressure cardiac tamponade and compared their clinical and catheterization data with those of patients with classic tamponade. A total of 1429 patients with pericarditis were evaluated, 279 of whom underwent combined pericardiocentesis and catheterization. Criteria of low-pressure cardiac tamponade were met in 29, whereas 114 had criteria of classic cardiac tamponade. Patients with low-pressure tamponade less frequently had clinical signs of tamponade, but the rate of constitutional symptoms, use of diuretics, and echocardiographic findings of tamponade were similar in both groups. Patients with low-pressure tamponade showed a significant increase in cardiac output after pericardiocentesis, but they usually had less severe cardiac tamponade compared with patients with classic tamponade. Prognosis was related mainly to the underlying disease. CONCLUSIONS: Low-pressure cardiac tamponade was identified in 20% of patients with catheterization-based criteria of tamponade. Clinical recognition may be difficult because of the absence of typical physical findings of tamponade in most patients. Although some patients are critically ill, most show a stable clinical condition. However, these patients obtain a clear benefit from pericardiocentesis.

[Diagnosis and management of acute pericardial syndromes]. / Orientación diagnóstica y manejo de los síndromes pericárdicos agudos.

Essentially, acute pericardial syndromes include acute pericarditis and cardiac tamponade. This article focuses on the diagnosis and management of acute pericarditis. In Spain, most cases of acute pericarditis whose etiology is not apparent at initial clinical presentation are either idiopathic or viral pericarditis, which follow a benign or self-limiting clinical course (although tamponade may develop in some patients). Knowledge of this basic epidemiologic fact is essential for the development of a rational management protocol that, on the one hand, avoids the unnecessary use of invasive pericardial diagnostic procedures in patients with idiopathic pericarditis and that, on the other hand, correctly identifies most cases of specific pericarditis, which mainly comprise purulent, tuberculous or neoplastic pericarditis. In accordance with this rationale and on the basis of our own experience, we have proposed a protocol for the management of acute pericardial disease that differs markedly from the "Guidelines on the Diagnosis and Management of Pericardial Disease" recently produced by the European Society of Cardiology. In addition, we have made some comments on the cardiac tamponade and the acute and subacute constrictive pericarditis that can occur during the resolution of acute pericarditis.

Orientación diagnóstica y manejo de los síndromes pericárdicos agudos / Diagnosis and management of acute pericardial syndromes

Los síndromes pericárdicos agudos incluyen básicamente la pericarditis aguda y el taponamiento cardíaco. El presente trabajo está dedicado fundamentalmente al manejo diagnóstico y terapéutico de la pericarditis aguda. En nuestro medio, la gran mayoría de pericarditis cuya causa no es evidente en la presentación clínica inicial corresponde a pericarditis idiopáticas o virales, que tienen un curso benigno y autolimitado (aunque algunos pacientes pueden desarrollar taponamiento cardíaco). Esta noción de prevalencia es fundamental para establecer un protocolo de manejo lógico que evite, por un lado, el excesivo uso de procedimientos invasivos del pericardio, pero que permita, por otro lado, diagnosticar los casos de pericarditis específicas (tuberculosa, purulenta y neoplásica). Según estas consideraciones y nuestra propia experiencia proponemos un protocolo de estudio y manejo de las enfermedades agudas del pericardio que difieren sustancialmente de las recientes «Guías de práctica clínica para el diagnóstico y tratamiento de las enfermedades del pericardio» de la Sociedad Europea de Cardiología. También se comentan aspectos del taponamiento cardíaco y de las formas de constricción aguda y subaguda que se pueden presentar en la fase de resolución de las pericarditis agudas

Essentially, acute pericardial syndromes include acute pericarditis and cardiac tamponade. This article focuses on the diagnosis and management of acute pericarditis. In Spain, most cases of acute pericarditis whose etiology is not apparent at initial clinical presentation are either idiopathic or viral pericarditis, which follow a benign or self-limiting clinical course (although tamponade may develop in some patients). Knowledge of this basic epidemiologic fact is essential for the development of a rational management protocol that, on the one hand, avoids the unnecessary use of invasive pericardial diagnostic procedures in patients with idiopathic pericarditis and that, on the other hand, correctly identifies most cases of specific pericarditis, which mainly comprise purulent, tuberculous or neoplastic pericarditis. In accordance with this rationale and on the basis of our own experience, we have proposed a protocol for the management of acute pericardial disease that differs markedly from the "Guidelines on the Diagnosis and Management of Pericardial Disease" recently produced by the European Society of Cardiology. In addition, we have made some comments on the cardiac tamponade and the acute and subacute constrictive pericarditis that can occur during the resolution of acute pericarditis

Effusive-constrictive pericarditis.

BACKGROUND: Effusive-constrictive pericarditis is an uncommon pericardial syndrome characterized by concomitant tamponade, caused by tense pericardial effusion, and constriction, caused by the visceral pericardium. We conducted a prospective study of its clinical evolution and management. METHODS: From 1986 through 2001, all patients with effusive-constrictive pericarditis were prospectively evaluated. Combined pericardiocentesis and cardiac catheterization were performed in all patients, and pericardiectomy was performed in those with persistent constriction. Follow-up ranged from 1 month to 15 years (median, 7 years). RESULTS: A total of 1184 patients with pericarditis were evaluated, 218 of whom had tamponade. Of these 218, 190 underwent combined pericardiocentesis and catheterization. Fifteen of these patients had effusive-constrictive pericarditis and were included in the study. All patients presented with clinical tamponade; however, concomitant constriction was recognized in only seven patients. At catheterization, all patients had elevated intrapericardial pressure (median, 12 mm Hg; interquartile range, 7 to 18) and elevated right atrial and end-diastolic right and left ventricular pressures. After pericardiocentesis, the intrapericardial pressure decreased (median value, -5 mm Hg; interquartile range, -5 to 0), whereas right atrial and end-diastolic right and left ventricular pressures, although slightly reduced, remained elevated, with a dip-plateau morphology. The causes were diverse, and death was mainly related to the underlying disease. Pericardiectomy was required in seven patients, all of whom had involvement of the visceral pericardium. Three patients had spontaneous resolution. CONCLUSIONS: Effusive-constrictive pericarditis is an uncommon pericardial syndrome that may be missed in some patients who present with tamponade. Although evolution to persistent constriction is frequent, idiopathic cases may resolve spontaneously. In our opinion, extensive epicardiectomy is the procedure of choice in patients requiring surgery.

[Clinical decision making based on cardiac diagnostic imaging techniques (I). Diagnosis and therapeutic management of patients with cardiac tamponade and constrictive pericarditis]. / Decisiones clínicas basadas en técnicas de imagen (I). Diagnóstico y guía terapéutica del paciente con taponamiento cardíaco o constricción pericárdica.

Echocardiography, thoracic computed tomography, and magnetic resonance imaging are three valuable imaging techniques for the management and pathophysiological understanding of cardiac tamponade and constrictive pericarditis. However, these techniques should not be used independently from clinical findings. In this article we describe the findings that can be obtained with these imaging techniques, emphasizing how they should be integrated in the clinical context of the patient. Only the proper use of these imaging techniques can optimize the management of patients with pericardial disease.

Diagnóstico y guía terapéutica del paciente con taponamiento cardíaco o constricción pericárdica / Diagnosis and therapeutic management of patients with cardiac tamponade and constrictive pericarditis

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Derrame pericárdico en el paciente anciano: ¿una enfermedad diferente? / Pericardial effusion in the elderly: a different disease?

Introducción y objetivos. El objetivo de este estudio es valorar si existen diferencias en el espectro etiológico y el curso clínico del derrame pericárdico en pacientes ancianos, como se ha sugerido, lo que implicaría un manejo clínico distinto en función de la edad del paciente. Métodos. Todos los ecocardiogramas practicados en nuestro hospital entre 1990 y 1996 fueron revisados para seleccionar aquellos con derrame pericárdico moderado o severo. Los pacientes con edad inferior a 66 años fueron incluidos en el grupo I, y aquellos con edad superior a 65 años fueron asignados al grupo II. Resultados. Se seleccionaron 322 pacientes con derrame moderado (122) o severo (200). En el grupo I fueron incluidos 221 pacientes (edad 15-65 años; media, 47) y 101 pacientes fueron asignados al grupo II (edad 66-88 años; media, 72,5). El derrame era severo en el 60 por ciento del grupo I y en el 66 por ciento del grupo II (p = NS), y se produjo taponamiento en 36 por ciento del grupo I y 38,6 por ciento del grupo II (p = NS). Las infecciones pericárdicas específicas (pericarditis tuberculosa y purulenta) fueron más frecuentes en el grupo I (el 5,9 frente al 0,9 por ciento; p < 0,05). No encontramos diferencias significativas en la incidencia de derrame pericárdico de etiología idiopática (el 33 frente al 38 por ciento) o neoplásica (el 14,4 frente al 10,8 por ciento). Durante el seguimiento (96 por ciento de pacientes; mediana, 11 meses, rango; 1-58 meses) la mortalidad fue similar en ambos grupos (el 24 frente al 30 por ciento), así como la evolución a constricción pericárdica (el 4 frente al 2 por ciento), pero la persistencia de derrame fue más frecuente en el grupo II (el 6,3 frente al 14 por ciento; p < 0,05). Conclusiones. Este estudio sugiere que el derrame pericárdico tiene, en general, una etiología, curso clínico y pronóstico similares en pacientes ancianos respecto a los de la población general. Por tanto, su manejo debería ser similar y cualquier posibilidad etiológica debe ser considerada en el diagnóstico diferencial, con independencia de la edad del paciente (AU)