ESC new Pericardial Guidelines: Brief Review and What Next Cte) aU WD ULL eer on RS Se LUA} Pee eer Den Reet g rem ates eee ESC. Pa tere) ah) a eV el] te Seen ee ae Sa ate a a elem tore Os a PT aM SAC) CO cee ae ge eee ee Pree arta Seah Na ee eee ee ee ae Petar Se aaa ea ae MeL Gere aa ae Camco) ol Colt eo TLCS REHABILITATION, ISRAEL HEART SOCIETY. CARDIAC REHABILITATION INSTITUTE, SHEBA MEDICAL CENTER, TEL BrCl (is evel eel NG TVs cna ce EuRorean eae ee) secety or, doi:10.1093/eurheartj/ehv318Introduction More than a decade has elapsed since the first international guidelines of the diagnosis and management of pericardial diseases were issued by the European Society of Cardiology (ESC) in 2004. Since then, significant advances have been made in this field due to several randomized double blinded controlled trials and also retrospective, as well as prospective, cohort studies that were conducted during this time frame. However, despite the amount of knowledge that has been accumulated, only Spanish and Brazilian national societies of cardiology have so far published national guidelines on the management of pericardial diseases. No official guidelines were issued by the American College of Cardiology/American Heart Association. Therefore, a demand for an updated document has become inevitable in order to summarize all new data and translate them into a set of recommendations which could be implemented in clinical practice. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 pareIntroduction (continued) For this purpose, the new guidelines, focused on the clinical management of patients with pericardial diseases were issued by the ESC in 2015. The full text of the 2015 guidelines reflects the progress that has been made so far: the manuscript contains 9 sections (excluding appendix and references), nearly 30 second - level subsections and covers 44 pages. Several new chapters are introduced for the first time in the current guidelines, as compared with the previous version. Today I was asked to give a brief talk and to focus on the management of acute and recurrent pericarditis based on the new ESC guidelines 2015. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 pare2015 ESC Guidelines on the diagnosis and management of pericardial diseases Chairpersons Yehuda Adler (Israel), Philippe Charron (France). Coordinator Massimo Imazio (Italy). Task Force Members Luigi Badano (Italy), Gonzalo Barén-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. Ristié (Serbia), Manel Sabaté Tenas (Spain), Petar Seferovic (Serbia), Karl Swedberg (Sweden), Witold Tomkowski (Poland). www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 pareEPIDEMIOLOGY www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 @ e EE iEpidemiological data + Few epidemiological data, especially from primary care. + The incidence of acute pericard has been reported as 27.7 cases per 100,000 population/year in an Italian urban area. + Pericarditis is responsible for 0.1% of all hospital admissions and 5% of emergency room admissions for chest pain. + Data collected from a Finnish national registry (2000-2009) showed a standardized incidence rate of hospitalizations for acute pericarditis of 3.32 per 100,000 person-years (0.20% of all cardiovascular admissions). + Men aged 16-65 years were at higher risk for pericarditis (relative risk 2.02) than women in the general admitted population, with the highest risk-difference among young adults compared to the overall population. Heart 2008;94:498-501 - Circulation 2014;130: 1601-1606 www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 pareEpidemiological data - what next? There is a need to gather much more specific epidemiological data - from different geographical areas and possibly from each country separately. These data are highly important for diagnosing the differing aetiology related to various areas and countries around the globe, and may provide an explanation in the difference in treatment between these different areas. In light of this a dedicated team is warranted that would be established by the ESC to examine and analyze the issue. www.escardio.org euAETIOLOGY www.escardio.org European Heart Journal (2015) - dol:10.1093/eurhearti/ehv318 @ e EE iAetiology of pericardial diseases A. Infectious causes Viral (common): Enteroviruses (coxsackieviruses, echoviruses), Herpesviruses (EBV, CMV, HHV-6), Adenoviruses, Parvovirus B19 (possible overlap with aetiologic viral agents of myocarditis). Bacterial: Mycobacterium tuberculosis (common, other bacterial rare), Coxiella burnetii, Borrelia burgdorferi, rarely: Pheumococcus spp, Meningococcus spp, Gonacoccus spp, Streptococcus spp, Staphylococcus spp, Haemophilus spp, Chlamydia spp, Mycoplasma spp, Legionella spp, Leptospira spp, Listeria spp, Providencia stuartii. Fungal (very rare): Histoplasma spp (more likely in immunocompetent patients), Aspergillus spp, Blastomyces spp, Candida spp (more likely in immunocompromised host). Parasitic (very rare): Echinococcus spp, Toxoplasma spp. Spp = Sepecies www.escardio.org European Heart @Aetiology of pericardial diseases (continued) B. Non-infectious causes Autoimmune (common): Systemic autoimmune and auto-inflammatory diseases (systemic lupus erythematosus, Sjégren syndrome, rheumatoid arthritis, scleroderma), systemic vasculitides (i.e. eosinophilic granulomatosis with polyangiitis or allergic granulomatosis, previously named Churg-Strauss syndrome, Horton disease, Takayasu disease, Behcet syndrome), sarcoidosis, familial Mediterranean fever, inflammatory bowel diseases, Stil! disease. Neoplastic: Primary tumours (rare, above all pericardial mesothelioma). Secondary metastatic tumours (common, above all lung and breast cancer, lymphoma). Metabolic: Uraemia, myxoedema, anorexia nervosa, other rare. Traumatic and Iatrogeni + Early onset (rare): + Direct injury (penetrating thoracic injury, aesophageal perforation), + Indirect injury (non-penetrating thoracic injury, radiation injury), + Delayed onset: Pericardial injury syndromes (common) postmyocardial infarction syndrome, postpericardiotomy syndrome, post-traumatic, including forms after iatrogenic trauma (e.g. coronary percutaneous intervention, pacemaker lead insertion and radiofrequency ablation) TODD DDD ADD AA ADD: | www.escardio.org oanAetiology of pericardial diseases (continued) B. Non-infectious causes (continued): Drug-related (rare): Lupus-like syndrome (procainamide, hydralazine, methyldopa, isoniazid, phenytoin); antineoplastic drugs (often associated with a cardiomyopathy, may cause a pericardiopathy): doxorubicin (adriamicin), daunorubicin, cytosine arabinoside, 5-fluorouracil, cyclophosphamide; penicillins as hypersensitivity pericarditis with eosinophilia; amiodarone, methysergide, mesalazine, clozapine, minoxidil, dantrolene, practolol, phenylbutazone, thiazides, streptomycin, thiouracils, streptokinase, p-aminosalicylic acid, sulfadrugs, cyclosporine, bromocriptine, several vaccines, GM-CSF, anti-TNF agents. Other (common): Amyloidosis, aortic dissection, pulmonary arterial hypertension and chronic heart failure. Other (uncommon): Congenital partial and complete absence of the pericardium. Spp = Sepecies @ www.escardio.org euAetiology of pericardial diseases - what next? We do not actually have a complete understanding as to the most frequent cause of pericarditis, i.e. the clear idiopathy . It is clear that a large number of causes are virus based but this has not been checked enough and is not clear. In light of this a dedicated team is warranted that would be established by the ESC to examine and analyze the issue. www.escardio.org European Heart Journal (2015) -dol:10.1093/eusheart/ehv318 aeraVarious Pericardial Syndromes . Pericarditis (acute, subacute, chronic and recurrent) . Pericardial Effusion 3. Cardiac Tamponade 4. Constrictive Pericarditis . Pericardial Masses.ACUTE PERICARDITIS @ i = www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 k KAcute Pericarditis Recommendations Class | Level ECG is recommended in all patients with suspected acute pericarditis. Transthoracic echocardiography is recommended in all patients with suspected acute pericarditis. Chest X-ray is recommended in all patients with suspected acute pericarditis. Assessment of markers of inflammation (i.e. C-reactive protein) and myocardial injury (i.e. CK, troponin) is recommended in patients with suspected acute pericarditis. ECG = electrocardiogram CK = creatinine kinase. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 pareAcute Pericarditis Recommendations Class | Level Hospital admission is recommended for high-risk patients with acute pericarditis (at least one risk factor). Outpatient management is recommended for low-risk patients with acute pericarditis. Evaluation of response to anti-inflammatory therapy is recommended after 1 week. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 pareCommonly prescribed anti-inflammatory drugs for acute pericar LeTaty<] Usual Dosing? Tx duration® Tapering? Aspirin 750-1000 mg _ | 1-2 weeks. Decrease doses by every 8 hours. 250-500 mg every 1-2 weeks. Ibuprofen | 600mg every | 1-2 weeks. Decrease doses by 8 hours. 200-400 mg every 1-2 weeks. Colchicine | 0.5 mg once 3 months. Not mandatory, (<70 kg) or alternatively 0.5 mg 0.5 mg b.i.d. every other day (270 kg). (<70 kg) or 0.5 mg once (270 kg) in the last weeks. b.i.d = twice daily; NSAIDs = non-steroidal anti-inflammatory drugs; Tx = treatment. *Tapering should be considered for aspirin and NSAIDs °Tx duration is Symptoms and CRP quided but generally 1 to 2 weeks for uncomplicated cases. Gastroprotection should be provided. Colchicine is added on top of aspirin or ibuprofen heartj/ehv318 socerr ot www.escardio.org Europear feart Journal (201 01:10. 1093/eAcute Pericarditis Recommendations Class | Level Aspirin or NSAIDs are recommended as first line therapy for acute pericarditis with gastroprotection. Colchicine is recommended as first line therapy for acute pericarditis as adjunct to aspirin/NSAIDs therapy. Serum CRP should be considered to guide the treatment length and assess the response to therapy. Low-dose corticosteroids? should be considered for acute pericarditis in cases of contraindication/failure of aspirin/ NSAIDs and colchicine, and when an infectious cause has been excluded, or when there is a specific indication such as auto- immune disease. CRP = C-reactive protein; ECG = electrocardiogram; NSAIDs = non-steroid anti-inflammatory drugs. 2Added to colchicine. www.escardio.org European Heart Journal (2 hearti/ehva18 pareAcute Pericarditis (continued) Recommendations Class | Level Exercise restriction should be considered for non-athletes with acute pericarditis untill symptom resolution, and normalization of CRP, ECG and echocardiogram. For athletes, the duration of exercise restriction should be considered until resolution of symptoms and normalization of CRP, ECG and echocardiogram, and for at least 3 months. Corticosteroids are not recommended as first line therapy for acute pericarditis. CRP = C-reactive protein; ECG = electrocardiogram; NSAIDs = non-steroid anti-inflammatory drugs. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 pareAcute Pericarditis - what next? Regarding etiology, the question remains regarding the idiopathic issue. In light of this a dedicated team is warranted that would be established by the ESC to examine and analyze the issue. feurhearti/ehv318 Seer or www.escardio.org European Heart Journal (2015) - doi:10.108RECURRENT PERICARDITIS @ www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 pareRecurrent Pericarditis Diagnostic criteria Pericarditis Definition and diagnostic criteria Acute Inflammatory pericardial syndrome to be diagnosed with at least 2 of the 4 following criteria: (1) pericarditic chest pain, (2) pericardial rubs, (3) new widespread ST-elevation or PR depression on ECG, (4) pericardial effusion (new or worsening). Additional supporting findings: - Elevation of markers of inflammation (i.e. C-reactive protein, erythrocyte sedimentation rate, and white blood cell count), - Evidence of pericardial inflammation by an imaging technique (CT, CMR). Incessant Pericarditis lasting for >4-6 weeks but <3 months? without remission. Recurrent —_| Recurrence of pericarditis after a documented first episode of acute pericarditis and a symptom-free interval of 4-6 weeks or longer. Chroni Pericarditis lasting for >3 months CMR = cardiac magnetic resonance; CT = computed tomography; ECG = electrocardiogram. Usually within 18-24 months but a precise upper limit of time has not been established. Circulation 2007;115:2739-2744. - N Eng! J Med 2013;369:1522-1528. Lancet 2014;50140-6736: 62709-9. - JAMA 2014,312:1016-1023 @ 1. Am Soc Echocardiogr 2013;26:965-1012.e15 - Eur Heart J Cardiovasc Imaging 2014;16:12-31 10. 1093/eurheartj/ehv318 Speer or www.escardio.org ztCommonly prescribed anti-inflammatory drugs for recurrent pericarditis Usual Initial dose* Bea CUT be weeks-months | Decrease doses by 500-1000 mg every 6-8 hours 250-500 mg every (range 1,5-4 g/day) 1-2 weeks? Ibuprofen 600 mg every Shours _| weeks-months | Decrease doses by (range 1200-2400 mg) 200-400 mg every 1-2 weeks Indomethacin | 25-50 mg every 8 hours: | weeks-months | Decrease doses by start at lower end of 25 mg every 1-2 weeks? dosing range and titrate upward to avoid headache and dizziness 0.5 mg twice or At least Not necessary, 0.5 mg daily for patients | 6 months alternatively 0.5 mg <70 kg or intolerant to every other day higher doses (<70 kg) or 0.5 mg once (270 kg) in the last weeks Tx = treatment. *Tapering should be considered for aspirin and NSAIDs. bLonger tapering times for more difficult, resistant cases may be considered. nal (2015) - dol:10.1093/ www.escardio.orgTherapeutic algorithm for acute and recurrent pericarditis Py eee ee eel a Mele Regia eons Recta ee eel ECG changes; pericardial effusion) Aspirin or NSAID + colchicine + exercise restriction Low-dose corticosteroids (in case of contraindications to aspirin/NSAID/colchicine and after exclusion of infectious cause) Pera eatin iy (after symptom-free interval 4-6 weeks) Low-dose corticosteroids (in case of contraindication to aspirin/NSAID/colchicine and after exclusion of infectious cause)Immunusuppresants and biological drugs for refractory cases Pre Cd POLO uo ud Lava Pou feos ey Azathioprine Initial: 1 mg/ka/day |Refer No dose adjustments: No dose Limited data |- Haematologic fiven once dally or. to adult |provided in manufacturer's |adwustments available: children| and hepatic divided twice dally, dosing. | label. Provided in’ [and adolescents: toxicity. cradvally increased manufacturer's oral: 2-2.5 ma/ka||- allopurinol ti 2-3 mg/kg/day. label. Dose once dally. [concomitant use Caution contraindicated however since (severe myelo- possible suppression). hepatotoxicity - Useful asa sparing corticosteroids agent. Wig 400-500 majka/éay [Refer [Use with caution due to risk [No dose Refer to adult | Generally well for S days, or to adut [of immune globulin-induced |acjustments _|dosing tolerated Tglkg/day for dosing. [renal dysfunction; the rate |provided in expensive: 2 days, eventually of infusion and manufacturers Eee tthe repeated every concentration of solution label. 4 weeks. should be minimized. jecute epincde. Anakinra, 1-2 mg/kg/day up to |Refer No dose adjustment is No dose 1-2 mg/kg/day | Generally well 100 mg once to adult | necessary. adustments _|subcuteneously {tolerated dailysubouteneously. |dosing. provided in {max 100 mg/day. |expensive. ee Effective in the Bel acute episode. www.escardio.org ~ dof:10.1093/eurheartj/ehv318 SeraManagement of recurrent pericarditis Recommendations Class | Level Aspirin and NSAIDs are mainstays of treatment and are recommended at full doses if tolerated, until complete symptom resolution. Colchicine (0.5 mg twice daily or 0.5 mg daily for patients <70 kg or intolerant to higher doses) use for 6 months is recommended as an adjunct to aspririn/NSAIDs. Colchicine therapy of longer duration (>6 months) should be considered in some cases, according to clinical response. CRP dosage should be considered to guide the treatment duration and assess the response to therapy. After CRP normalization a gradual tapering of therapies should be considered, tailored to symptoms and CRP, a single class of drugs at atime. Drugs such IVIG, anakinra or azathioprine may be considered in cases of corticosteroid dependent recurrent pericarditis in patients not responsive to colchicine. hearti/ehv318 socerr ot www.escardio.org European Heart Journal (2015Management of recurrent pericarditis (continued) Recommendations Class | Level Exercise restriction should be considered for non-athletes with recurrent pericarditis untill symptom resolution and CRP normalization, taking into account the previous history and clinical conditions. Exercise restriction for a minimum of 3 months should be considered for athletes with recurrent pericarditis till symptom resolution and normalization of CRP, ECG and echocardiogram. If ischaemic heart disease is a concern or antiplatelet therapy is required, aspirin should be considered, at medium high doses (1-2.4 g/daily) (Web-box). If symptoms recur during therapy tapering, the management should consider not to increase the dose of corticosteroids and to control symptoms by increasing to the maximum dose of aspirin or NSAIDs, well distributed, generally every 8 hours, intravenously if necessary, adding colchicine, and adding analgesics for pain control. Cortosteroid therapy is not recommended as a first line-approach. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318Management of recurrent pericarditis-what next? The greatest challenge is with patients who have not responded to conventional treatment — including NSAID and / or corticosteroids and colchicine. Recently there has been promising data regarding the effectiveness of Anakinra. Prospective, double blind research is necessary to discern the effectiveness of IVIG, Azathioprine and Anakinra... www.escardio.org European Heart Journal (2015) -dMYOPERICARDITIS @ i = www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 k KPericarditis with myocardial involvement Recommendations Class | Level In cases of pericarditis with suspected associated myocarditis, coronary angiography (according to clinical presentation and risk factor assessment) is recommended in order to rule out acute coronary syndromes. Cardiac Magnetic Resonance (CMR) is recommended for the confirmation of myocardial involvement. Hospitalization is recommended for diagnosis and monitoring in patients with myocardial involvement. Rest and avoidance of physical activity beyond normal sedentary activities is recommended in non-athletes and athletes with myopericarditis for a duration of 6 months. Empirical anti-inflammatory therapies (lowest efficacious doses) should be considered to control chest pain. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318Pericarditis with myocardial involvement-what next? We don’t have any data regarding the duration or intensity of treatment for pericarditis cases that present with myocardial involvement: Is this a more severe disease regarding the pericard because of the myocardial involvement? Is this disease identical to pericarditis without the myocardial involvement? To summarize: Perspective research is required in order to compare between patients with pure pericai is that don’t have myocardial involvement to patients with perimyocarditis. www.escardio.org European Heart Journal (2015) -dPERICARDIAL EFFUSION @ i = www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 k KClassification of pericardial effusion Onset Acute Subacute Chronic (>3 months) Size Mild <10 mm Moderate 10-20 mm Large >20 mm Distribution Circumferential Loculated Composition Transudate Exudate Eur Heart J 2013;34:1186-1197 - Eur Heart J Cardiovasc Imaging 2014;16:12-31 www.escardio.org doi:10.1093/eurheartj/ehv318 Speer orPericardial Effusion Recommendations Transthoracic echocardiography is recommended in all patients with suspected pericardial effusion. Chest X-ray is recommended in patients with a suspicion of pericardial effusion or pleuropulmonary involvement. Assessment of markers of inflammation (i.e. CRP) are recommended in patients with pericardial effusion. CT or CMR should be considered in suspected cases of loculated pericardial effusion, pericardial thickening and masses, as well as associated chest abnormalities. CMR = cardiomyopathy; CRP = C-reactive protein; CT = computed tomography. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318A simplified algorithm for pericardial effusion triage and management er eu Reet a elgg ce teeter Tae Les ele a Ea) Elevated inflammatory Eres ae nea) markers? Secu nine Known associated Re SAC ure disease? eects acs Large (>20 mm) Resume eecs pericardial effusion? ir 3 months) Fallew-tip www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 pare Eur Heart J 2013;34:1186-1197Pericardial Effusion Recommendations Class | Level Admission is recommended for high-risk patients with pericardial Effusion=. A triage of patients with pericardial effusion is recommended as in Figure 3. Similar risk criteria as for pericarditis. Recommendations Class | Level It is recommended to target the therapy of pericardial effusion at the aetiology. Aspirin/NSAIDs/colchicine and treatment of pericarditis is recommended when pericardial effusion is associated with systemic inflammation. Pericardiocentesis, or cardiac surgery, is indicated for cardiac tamponade, or for symptomatic moderate to large pericardial effusions not responsive to medical therapy, and for suspicion of unknown bacterial or neoplastic aetiology. NSAIDs = non-steroid anti-inflammatory drugs. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 persPericardial Effusion - what next? We do not have enough data regarding the recommended approach to chronic moderate pericardial effusion: Should it be a conservative approach? Pericardiocentesis? Other? Research is needed on this issue. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 parePost-cardiac injury syndromes + PCIS is an umbrella term indicating a group of inflammatory pericardial syndromes including post-myocardial infarction pericarditis, post-pericardiotomy syndrome (PPS), and post-traumatic pericarditis (either iatrogenic or not). + Such syndromes are presumed to have an autoimmune pathogenesis triggered by an initial damage to pericardial and/or pleural tissues. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 pareDiagnostic criteria for post-cardiac injury syndrome (PCIS) including Post-Pericardiotomy Syndrome (PPS) . Fever without alternative causes. . Pericarditic or pleuritic chest pain. . Pericardial or pleural rubs. . Evidence of pericardial effusion. . Pleural effusion with elevated CRP. At least 2 of 5 criteria should be fulfilled. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 parePCIS Recommendations Class | Level Anti-inflammatory therapy is recommended in patients with PCIS to hasten symptoms remission and reduce recurrences. Aspirin? is recommended as first choice for anti-inflammatory therapy of post-myocardial infarction pericarditis and those patients already on antiplatelet therapies. Colchicine added to aspirin or NSAIDs should be considered for the therapy of PCIS, as in acute pericarditis. Colchicine should be considered after cardiac surgery using weight- adjusted doses (i.e. 0.5 mg once for patients <70 Kg and 0.5 mg ‘twice daily if patients are >70 kg) and without a loading dose for the prevention of PPS if there are no contraindications and it is tolerated. Preventive administration of colchicine is recommended for 1 month. Careful follow-up after PCIS should be considered to exclude possible evolution towards constrictive pericarditis with echocardiography every 6-12 months according to clinical features and symptoms. NSAIDs = non-steroidal anti-inflammatory drugs; PCIS = post-cardiac injury syndromes; PPS = post-pericardiotomy syndrome. *Antiplatelet effects of aspirin have been demonstrated up to doses of 1.5 g/day. There are no data for or against the use of higher doses in this setting. hearti/ehv318 www.escardio.org éPCIS - what next? Highly promising evidence regarding the effectiveness of colchicine as prophylactic treatment for PCIS has presented in 2 large trials that were published in Israel and Italy. An extensive, prospective, double blind, multi instituti nal research is necessary in order to provide the defi www.escardio.org euNeoplastic Disease + The definite diagnosis is based on the confirmation of the malignant infiltration within pericardial fluid (cytology) or tissue (biopsy). + Primary tumours of the pericardium, either benign (lipomas and fibromas) or malignant (mesotheliomas, angiosarcomas, fibrosarcomas) are very rare. + Mesothelioma, the most common malignant tumour, is almost always incurable. + The most common secondary malignant tumours are lung cancer, breast cancer, malignant melanoma, lymphomas, and leukemias. www.escardio.org European Heart Journal (2015) - doi:10.1093/eurheart/ehv318 parePericardial involvement in neoplastic disease (1) Recommendations Class | Level Pericardiocentesis is recommended for cardiac tamponade to relieve symptoms and establish the diagnosis of malignant pericardial effusion. Cytological analyses of pericardial fluid are recommended for the confirmation of malignant pericardial disease. Pericardial or epicardial biopsy should be considered for the confirmation of malignant pericardial disease. Tumor marker testing should be considered for distinguishing malignant from benign effusions in pericardial fluid. Systemic antineoplastic treatment is recommended in confirmed cases of neoplastic aetiology. Extended pericardial drainage is recommended in patients with suspected or definite neoplastic pericardial effusion in order to prevent effusion recurrence and provide a way for intrapericardial therapy. www.escardio.orgPericardial involvement in neoplastic disease (2) Recommendations Class | Level Intrapericardial instillation of cytostatic/sclerosing agents should be considered since it may prevent recurrences in patients with malignant pericardial effusion. Radiation therapy should be considered to control malignant pericardial effusion in patients with radiosensitive tumours such as lymphomas and leukaemias. Pericardiotomy should be considered when pericardiocentesis cannot be performed. Percutaneous balloon pericardiotomy may be considered for the prevention of recurrences of neoplastic pericardial effusions. Pericardial window creation via left minithoracotomy may be considered in surgical treatment of malignant cardiac tamponade. Interventional techniques should consider the potentiality of seeding of neoplastic cells, patient prognosis, and the overall quality of life of the patients. www.escardio.org European Heart Journal (2015 hearti/ehva18 pareNeoplastic Disease -what next? It is known that there are 5 common tumors that “like” the pericardium (lung, breast, lymphoma, leukemia and melanoma) and it is interesting that tumors such as esophageal, prostatic and others are not seen or if at all in the pericardium. Is there excretion of an anti cancer substance in the pericardium? www.escardio.org European Heart Journal (2015) -dol:10.1093/eurheart/ehv318 aeraPericardial cavity LISTENING!