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2015 ESC Guidelines for the Diagnosis and Management Of European Heart Journal ESC GUIDELINES doi:10.1093/eurheartj/ehv318 2015 ESC Guidelines for the diagnosis and management of pericardial diseases – Web Addenda 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) Authors/Task Force Members: Yehuda Adler* (Chairperson) (Israel), Philippe Charron* (Chairperson) (France), Massimo Imazio† (Italy), Luigi Badano (Italy), Gonzalo Baro´ n-Esquivias (Spain), Jan Bogaert (Belgium), Antonio Brucato (Italy), Pascal Gueret (France), Karin Klingel (Germany), Christos Lionis (Greece), Bernhard Maisch (Germany), Bongani Mayosi (South Africa), Alain Pavie (France), Arsen D. Ristic´ (Serbia), Manel Sabate´ Tenas (Spain), Petar Seferovic (Serbia), Karl Swedberg (Sweden) and Witold Tomkowski (Poland) Document Reviewers: Stephan Achenbach (CPG Review Coordinator) (Germany), Stefan Agewall (CPG Review Coordinator) (Norway), Nawwar Al-Attar (UK), Juan Angel Ferrer (Spain), Michael Arad (Israel), Riccardo Asteggiano (Italy), He´ctor Bueno (Spain), Alida L. P. Caforio (Italy), Scipione Carerj (Italy), Claudio Ceconi (Italy), Arturo Evangelista (Spain), Frank Flachskampf (Sweden), George Giannakoulas (Greece), Stephan Gielen * Corresponding authors: Yehuda Adler, Management, Sheba Medical Center, Tel Hashomer Hospital, City of Ramat-Gan, 5265601, Israel. Affiliated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel, Tel: +972 03 530 44 67, Fax: +972 03 530 5118, Email: [email protected]. Philippe Charron, Service de Cardiologie, Chu Ambroise Pare´, 9 av Charles de Gaulle, 92104 Boulogne Billancourt, France, Tel: +33149095543,Fax:+33142161364, Email: [email protected]. †Massimo Imazio: Coordinator, affiliation listed in the Appendix. ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies document reviewers: listed in Appendix. a Representing the European Association for Cardio-Thoracic Surgery (EACTS). ESC entities having participated in the development of this document. ESC Associations: Acute Cardiovascular Care Association (ACCA), European Association for Cardiovascular Prevention and Rehabilitation (EACPR), European Association of Cardiovascular Imaging (EACVI), European Association of Percutaneous Cardiovascular Interventions (EAPCI), Heart Failure Association (HFA). ESC Councils: Council for Cardiology Practice (CCP), Council on Cardiovascular Nursing and Allied Professions (CCNAP), Council on Cardiovascular Primary Care (CCPC). ESC Working Groups: Cardiovascular Pharmacotherapy, Cardiovascular Surgery, Grown-up Congenital Heart Disease, Myocardial and Pericardial Diseases, Pulmonary Circulation and Right Ventricular Function, Valvular Heart Disease. The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC. Disclaimer: The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom- mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour- aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. &The European Society of Cardiology 2015. All rights reserved. For permissions please email: [email protected]. Page 2 of 12 ESC Guidelines (Germany), Gilbert Habib (France), Philippe Kolh (Belgium), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), George Lazaros (Greece), Ales Linhart (Czech Republic), Philippe Meurin (France), Koen Nieman (The Netherlands), Massimo F. Piepoli (Italy), Susanna Price (UK), Jolien Roos-Hesselink (The Netherlands), Franc¸ois Roubille (France), Frank Ruschitzka (Switzerland), Jaume Sagrista` Sauleda (Spain), Miguel Sousa-Uvaa (Portugal), Jens Uwe Voigt (Belgium) and Jose Luis Zamorano (Spain) The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines. ---------------------------------------------------------------------------------------------------------------------------------------------------------- Keywords Guidelines † Aetiology † Constrictive pericarditis † Diagnosis † Myopericarditis † Pericardial effusion † Pericardiocentesis † Pericarditis † Pericardium † Prognosis † Tamponade † Therapy List of Web Tables and Figures Web Tables . 7 Web Figures . 2 References . 12 WebBox..................................... 6 Web Figures Panel A Web Figure 1 Diffuse ST elevation (typically concave up) with PR depression in some leads in a patient with acute pericarditis.5 ESC Guidelines Page 3 of 12 AB Ao = aorta; LA = left atrium; LV = Left Ventricle; pe = pericardial effusion; RV = right ventricle. Web Figure 2 Semi-quantitative assessment of the size of pericardial effusion is based on the measure of the largest telediastolic echo-free space according to several echocardiographic views. Panel A. A mild pericardial effusion (,10 mm) is generally located posteriorly and adiacent to the RA. Panel B. In moderate (10–20 mm) and large (.20 mm) ones, the effusions become circumferential.48 Page 4 of 12 ESC Guidelines ABRapid pericardial effusion Slow pericardial effusion Cardiac tamponade Cardiac tamponade Pressure Pressure Limit of Limit of pericardial pericardial stretch stretch Pericardial reserve volume Pericardial reserve volume Volume Volume Web Figure 3 Pressure/volume curve of the pericardium with fast accumulating pericardial fluid leading to cardiac tamponade with a smaller volume (A) compared with the slowly accumulating pericardial fluid reaching cardiac tamponade only after larger volumes (B).48 ESC Guidelines Page 5 of 12 EVIDENCE OF CARDIAC TAMPONADE 1. Malignant disease 2 2. Tuberculosis 2 3. Recent radiotherapy 1 STEP 1 4. Recent viral infection 1 5. Recurrent PE, previous pericardiocentesis 1 SCORE THE AETIOLOGY 6. Chronic terminal renal failure 1 7. Immunodeficiency or immunosuppression 1 8. Hypo- or hyperthyroidism –1 9. Systemic autoimmune disease –1 + 1. Dyspnea/Tachypnea 1 2. Orthopnea (No rales on lung auscultation) 3 3. Hypotension (SBP <95 mmHg) 0.5 4. Progressive sinus tachycardia (in the absence 1 STEP 2 of medications afecting HR, hypothyreosis SCORE THE CLINICAL and uremia 5. Oliguria 1 PRESENTATION 6. Pulsus paradoxus >10 mmHg 2 7 . Pericardial chest pain 0.5 8. Pericardial friction rub 0.5 9. Rapid worsening of symptoms 2 10. Slow evolution of the disease –1 + 1. Cardiomegaly on chest x-ray 1 2. Electrical alternans on ECG 0.5 3. Microvoltage in ECG 1 4. Circumferential PE (>2 cm in diastole) 3 5. Moderate PE (1–2 cm diastole) 1 STEP 3 6. Small PE (<1 cm in diastole), no trauma –1 SCORE THE IMAGING 7. Right atrial collapse >1/3 of cardiac cycle 1 8. IVC >2.5 cm, <50% inspiratory collapse 1.5 9. Right ventricular collapse 1.5 10. Left ventricular collapse 2 11. Mitral/tricuspid respiratory flow variations 1 12. Swinging heart 1 URGENT SURGICAL MANAGEMENT (REGARDLESS OF THE SCORE) CALCULATE THE 1. Type A aortic dissection CUMULATIVE SCORE 2. Ventricular free wall rupture after acute (SUM OF SCORES FROM STEPS 1+2+3) myocardial infarction 3. Severe recent chest trauma 4. Iatrogenic haemoperacardium when the bleeding cannot be controlled percutaneously <6 SCORE >6 URGENT PERICARDIOCENTESIS PERICARDIOCENTESIS (IMMEDIATELY AFTER CAN BE POSTPONED CONTRAINDICATIONS ARE RULED OUT) (for up to 12/48h) PE = pericardial effusion; IVC = inferior vena cava; SBP = systolic blood pressure. Web Figure 4 Triage cardiac tamponade proposed by the European Society of Cardiology Working Group on myocardial and pericardial diseases.74 Page 6 of 12 ESC Guidelines Web Box used, low-dose aspirin should not be discontinued if indicated, even though concomitant administration of the two may amplify Aspirin and NSAIDs in pericardial the risk of upper gastrointestinal bleeding and
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