The main focus of the current guidelines is clinical management of pericardial diseases.

A substantial huge amount of new data have become available in the last 10 years: first
multicentre RCTs, first epidemiological and observational studies with> 100 patients have
been published soliciting new guidelines.
The main 10 new things that have been published and will affect contemporary management
of these diseases include:
1. Probabilistic and epidemiological approach to the aetiology. Pericardial diseases may
be caused by a wide range of causes but there are main aetiologies that should be especially
ruled out: tuberculosis (the most common cause of pericardial diseases all over the world and
especially relevant in developing countries), cancer, systemic inflammatory diseases, postcardiac injury syndromes.
2. Statement of definitions and diagnostic criteria for acute and recurrent pericarditis
(see table 1). Such definitions and criteria will help the clinicians to establish the diagnosis
but also will help to standardize the terminology for future studies and research.
Table 1. Diagnostic criteria and definitions

3. New role of markers of inflammation (especially C-reactive protein) to confirm the

diagnosis and monitor the activity of the disease: this will help to individualize the therapy
and provide duration of the anti-inflammatory therapy till symptoms resolution and
normalization of C-reactive protein.
4. New role of imaging to assess pericardial inflammation. Pericardial inflammation can
be identified by CT (contrast-enhancement of the inflamed pericardium) but especially by
CMR that allows detecting pericardial oedema on T2-weighted imaging and pericardial late
gadolinium enhancement as expression of organizing pericarditis. In atypical of doubtful
presentations this will allow reaching the diagnosis of pericarditis.
5. Triage of pericarditis. Specific features at presentation have been identified as major poor
prognostic predictors (fever>38C, subacute course, large pericardial effusion, cardiac
tamponade, lack of response to empiric anti-inflammatory therapy) that could be helpful to
identify patients at high risk of complications and non-idiopathic or non-viral aetiologies to
be admitted and investigated. Additional features may require monitoring: associated
myocarditis, immunodepression or immunosuppression, trauma, and oral anticoagulant
therapy. Low risk cases without these features can be managed as outpatient.

6. New therapeutic schemes and dosing for acute pericarditis. High doses of antiinflammatory every 8 hours till symptoms resolution and C-reactive protein normalization
will help to improve remission rates and reduce recurrences especially with the adjunct of
colchicine on top of standard anti-inflammatory therapies (table 2).
Table 2. Therapeutic schemes for acute pericarditis

7. Therapeutic algorhytm for recurrent pericarditis. Aspirin and NSAID plus colchicine
are mainstay of therapy for acute and recurrent pericarditis. Corticosteroids are a second
option to be considered in patients not responding to first line therapies or for specific
indications (e.g. pregnancy, systemic inflammatory diseases already on corticosteroids). In
cases that do not respond to these therapies or a combination of them, emerging options are
highlighted: azathioprine, IVIG, and anakinra. Pericardiectomy is the last option in
experienced centres (Figure 1).

8. Triage of pericardial effusion. In cases with cardiac tamponade or a suspicion of a

bacterial or neoplastic aetiology pericardiocentesi is indicated as well as admission.
Otherwise a triage is proposed considering the presence of a missed diagnosis of pericarditis,
the presence of an underlying systemic disease as a cause of the effusion (up to 60% of these
cases), and the size and duration of the effusion. Large (>20mm) and chronic (>3 months)
pericardial effusions may progress to cardiac tamponade in case of pericarditis or trauma.
Thus, pericardiocentesis should be considered for these patients without pericarditis or
another cause of the effusion (Figure 2).

9. Transient constrictive pericarditis. New-onset constrictive pericarditis may be transient

and cured by empiric anti-inflammatory therapy in case of pericarditis (e.g. evidence of
elevated C-reactive protein or pericardial inflammation on imaging) thus preventing
pericardiectomy.
10. Specific management issues for children and pregnancy. Specific indications,
contraindications and therapeutic schemes are proposed for children, pregnant women but
also elderly and in case of hepatic or renal disease.
In conclusion these new guidelines will promote a more evidence-based management of
pericardial disease and will assist the clinician in everyday clinical practice.

References

1. Authors/Task Force Members, Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines
for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis
and Management of Pericardial Diseases of the European Society of Cardiology
(ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur

Heart J. 2015 Nov 7;36(42):2921-64. doi: 10.1093/eurheartj/ehv318. Epub 2015 Aug 29.
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2. Maisch B, Seferovi PM, Risti AD, Erbel R, Rienmller R, Adler Y, Tomkowski WZ,
Thiene G, Yacoub MH; Task Force on the Diagnosis and Management of Pricardial Diseases
of the European Society of Cardiology. Guidelines on the diagnosis and management of
pericardial diseases executive summary; The Task force on the diagnosis and management of
pericardial diseases of the European society of cardiology. Eur Heart J. 2004 Apr;25(7):587610. PubMed PMID: 15120056.
The content of this article reflects the personal opinion of the author/s and is not necessarily
the official position of the European Society of Cardiology.