今日の臨床サポート

心膜炎

著者: 朝倉正紀 兵庫医科大学 循環器内科

監修: 今井靖 自治医科大学 薬理学講座臨床薬理学部門・内科学講座循環器内科学部門

著者校正/監修レビュー済:2019/09/06
患者向け説明資料

概要・推奨   

  1. 再発性心膜炎にはコルヒチンの投与が有効である(推奨度2
  1. 心膜炎におけるステロイドの有効性ははっきりとした結論には至っておらず、ほかの抗炎症薬効果がない場合に限定されるほうが望ましい。
  1. 心筋梗塞後の心膜炎では、アスピリンとインドメタシンは同等の有効性を示す(推奨度2
  1. 閲覧にはご契約が必要となります。閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
閲覧にはご契
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
朝倉正紀 : 講演料(大塚製薬(株),小野薬品工業(株),アストラゼネカ(株),ノバルティスファーマ(株),第一三共(株),バイエル薬品(株)),研究費・助成金など(第一三共(株)),奨学(奨励)寄付など(大塚製薬(株))[2021年]
監修:今井靖 : 講演料(第一三共株式会社)[2021年]

改訂のポイント:
  1. 定期レビューを行い、尿毒症性心膜炎などについて加筆修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 心膜炎は、急性もしくは慢性に起こる炎症性もしくは感染性疾患である。
  1. 心膜炎の原因として、特発性、感染(ウイルス性や結核性など)、自己免疫性(関節リウマチや全身性エリテマトーデスなど)、薬剤性、尿毒症性、悪性腫瘍の転移、心筋梗塞後(Dressler症候群)、心臓手術後など多様である。
  1. 病理学的に、線維素性、漿液性、血性、膿性に分類される。
問診・診察のポイント  
  1. 体位で変動する胸痛が特徴的であり、その有無を確認する(体位で変動することが急性心筋梗塞との鑑別に有用)。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Massimo Imazio, Rita Trinchero
雑誌名: Int J Cardiol. 2007 Jun 12;118(3):286-94. doi: 10.1016/j.ijcard.2006.07.100. Epub 2006 Oct 17.
Abstract/Text The pericardium is involved in a large number of systemic disorders, and acute pericarditis may be due to several causes. The diagnosis is based on clinical criteria, and laboratory testing is not routinely recommended. Deciding on the extent of the diagnostic evaluation requires good clinical judgement based on a careful evaluation of the risk-benefit ratio, and knowledge of basic epidemiological data for the development of a rational management program. In clinical practice a probabilistic approach seems reasonable: in Western countries most cases are idiopathic or viral with a brief and benign course and an excellent response to non-steroidal anti-inflammatory drugs, thus an extensive diagnostic evaluation is not routinely necessary. On the contrary, in developing countries specific pericarditis such as tuberculous pericarditis is quite common and should be ruled out. A clinical triage is feasible on a clinical basis. Patients with pericarditis can be safely managed on an outpatient basis without a thorough diagnostic evaluation unless the patient has high risk features such as temperature >38 degrees C, a subacute onset, immunodepression, a history of recent trauma, oral anticoagulant therapy, myopericarditis, a large pericardial effusion, and cardiac tamponade. The reported diagnostic yield of extensive laboratory evaluation and pericardiocentesis is low in the absence of cardiac tamponade or suspected purulent, tuberculous, and neoplastic pericarditis. Invasive procedures should be limited mainly to patients in whom therapeutic intervention is necessary.

PMID 17049636  Int J Cardiol. 2007 Jun 12;118(3):286-94. doi: 10.1016/・・・
著者: Massimo Imazio, Brunella Demichelis, Iris Parrini, Marco Giuggia, Enrico Cecchi, Gianni Gaschino, Daniela Demarie, Aldo Ghisio, Rita Trinchero
雑誌名: J Am Coll Cardiol. 2004 Mar 17;43(6):1042-6. doi: 10.1016/j.jacc.2003.09.055.
Abstract/Text OBJECTIVES: We sought to investigate the safety and efficacy of a protocol for acute pericarditis triage and outpatient management of low-risk cases.
BACKGROUND: Acute pericarditis has generally a brief and benign course after empiric treatment by non-steroidal anti-inflammatory drugs, and routine hospitalization of most patients may be unnecessary.
METHODS: From January 1996 to December 2001, all consecutive cases of acute pericarditis were evaluated on a day-hospital basis. Patients without clinical poor prognostic predictors (fever >38 degrees C, subacute onset, immunodepression, trauma, oral anticoagulant therapy, myopericarditis, severe pericardial effusion, cardiac tamponade) were considered low-risk cases and assigned to outpatient treatment with high-dose oral aspirin. Patients with poor prognostic predictors or aspirin failure were hospitalized for etiology search and treatment. A clinical and echocardiographic follow-up was performed at 48 to 72 h, 7 to 10 days, 1 month, 6 months, and 1 year.
RESULTS: Two hundred fifty-four out of 300 (84.7%) patients were selected as low-risk cases. Outpatient treatment was efficacious in 221 out of 254 (87%) cases. Thirty-three out of 254 patients were hospitalized because of aspirin failure. Patients treated on an out-of-hospital basis had no serious complications after a mean follow-up of 38 months (no cases of cardiac tamponade). A higher frequency of recurrences and constriction was recorded in aspirin-resistant cases than in aspirin responders (60.6% vs. 10.4% for recurrences and 9.1% vs. 0.5% for constriction, respectively; all p < 0.01).
CONCLUSIONS: A protocol for acute pericarditis triage and outpatient therapy of low-risk cases is safe and efficacious and may reduce management costs.

PMID 15028364  J Am Coll Cardiol. 2004 Mar 17;43(6):1042-6. doi: 10.10・・・
著者: R Zayas, M Anguita, F Torres, D Giménez, F Bergillos, M Ruiz, M Ciudad, A Gallardo, F Vallés
雑誌名: Am J Cardiol. 1995 Feb 15;75(5):378-82.
Abstract/Text To assess the incidence of a specific etiology and the role of methods for specific etiologic diagnosis in patients with primary acute pericarditis, we studied 100 patients with primary acute pericarditis consecutively admitted to our hospital between 1991 and 1993. A general diagnostic protocol was performed in all patients, whereas only pericardiocentesis was performed in patients with clinical cardiac tamponade or an unfavorable course with anti-inflammatory drugs. Surgical drainage and pericardial biopsy was performed in patients with tamponade relapse. A specific etiology was discovered in 22 patients (22%) (neoplasms in 7, tuberculosis in 4, other infections in 3, collagen diseases in 3, thyroid disorders in 4, and dissecting aortic aneurysm in 1). The general diagnostic protocol led to a specific diagnosis in 15 patients (68% of all patients with specific acute pericarditis) and pericardiocentesis in the other 7 patients (32%). The role of a diagnostic protocol, therapeutic pericardiocentesis, and diagnostic pericardiocentesis was similar and complementary. Pericardial biopsy results were negative in the 5 patients in whom it was performed. Cardiac tamponade and an unfavorable clinical outcome were significantly (p < 0.001) associated with the finding of a specific etiology; when both features were combined, sensitivity was 86% and specificity 85%, positive predictive value 63% and negative predictive value 96%. We conclude that the specific etiology in patients with primary acute pericarditis is about 20% to 25%, and that about 90% of these specific cases can be discovered by using the described systematic diagnostic protocol only in patients with an unfavorable outcome (cardiac tamponade or poor clinical course).

PMID 7856532  Am J Cardiol. 1995 Feb 15;75(5):378-82.
著者: G Permanyer-Miralda, J Sagristá-Sauleda, J Soler-Soler
雑誌名: Am J Cardiol. 1985 Oct 1;56(10):623-30.
Abstract/Text A series of 231 patients with "primary" acute pericardial disease (acute pericarditis or tamponade presenting without an apparent cause) were studied according to the following protocol: general clinical and laboratory studies (stage I), pericardiocentesis (stage II), pericardial biopsy (stage III) and blind antituberculous therapy (stage IV). In 32 patients (14%) a specific etiologic diagnosis was obtained (13 with neoplasia, 9 with tuberculosis, 4 with collagen vascular disease, 2 with toxoplasmosis, 2 with purulent pericarditis and 2 with viral pericarditis). "Diagnostic" pericardiocentesis (32 patients) was performed when clinical activity and effusion persisted for longer than 1 week or when purulent pericarditis was suspected, whereas "therapeutic" pericardiocentesis (44 patients) was performed to treat tamponade; their diagnostic yield was 6% and 29%, respectively. "Diagnostic" biopsy (20 patients) was carried out when illness persisted for longer than 3 weeks, whereas "therapeutic" biopsy was performed whenever pericardiocentesis failed to relieve tamponade; their diagnostic yield was 5% and 54%, respectively. The diagnostic yield difference between "diagnostic" and "therapeutic" procedures was significant (p less than 0.001); in contrast, the global diagnostic yield of pericardiocentesis (19%) and biopsy (22%) was similar. At the end of follow-up (1 to 76 months, mean 31 +/- 20), no patient in whom a diagnosis of idiopathic pericarditis had been made showed signs of pericardial disease. It is concluded that a "diagnostic" procedure is not warranted as a routine method, a choice between "therapeutic" pericardiocentesis and biopsy is circumstantial and must be individualized, and only through a systematic approach can a substantial diagnostic yield be reached in primary acute pericardial disease.

PMID 4050698  Am J Cardiol. 1985 Oct 1;56(10):623-30.
著者: Massimo Imazio, Enrico Cecchi, Brunella Demichelis, Salvatore Ierna, Daniela Demarie, Aldo Ghisio, Franco Pomari, Luisella Coda, Riccardo Belli, Rita Trinchero
雑誌名: Circulation. 2007 May 29;115(21):2739-44. doi: 10.1161/CIRCULATIONAHA.106.662114. Epub 2007 May 14.
Abstract/Text BACKGROUND: The clinical search for indicators of poor prognosis of acute pericarditis may be useful for clinical triage of patients at high risk of specific causal conditions or complications. The aim of the present article is to assess the relationship between clinical features at presentation and specific causes or complications.
METHODS AND RESULTS: A total of 453 patients aged 17 to 90 years (mean age 52+/-18 years, 245 men) with acute pericarditis (post-myocardial infarction pericarditis was excluded) were prospectively evaluated from January 1996 to August 2004. A specific cause was found in 76 of 453 patients (16.8%): autoimmune in 33 patients (7.3%), neoplastic in 23 patients (5.1%), tuberculous in 17 patients (3.8%), and purulent in 3 patients (0.7%). In multivariable analysis, women (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.03 to 2.70; P=0.036) and patients with fever >38 degrees C (HR 3.56, 95% CI 1.82 to 6.95; P<0.001), subacute course (HR 3.97, 95% CI 1.66 to 9.50; P=0.002), large effusion or tamponade (HR 2.15, 95% CI 1.09 to 4.23; P=0.026), and failure of aspirin or of nonsteroidal anti-inflammatory drugs (HR 2.50, 95% CI 1.28 to 4.91; P=0.008) were at increased risk of specific causal conditions. After a mean follow-up of 31 months, complications were detected in 95 patients (21.0%): recurrences in 83 patients (18.3%), tamponade in 14 patients (3.1%), and constriction in 7 patients (1.5%). In multivariable analysis, women (HR 1.65, 95% CI 1.08 to 2.52; P=0.020) and patients with large effusion or tamponade (HR 2.51, 95% CI 1.37 to 4.61; P=0.003) and failure of aspirin or of nonsteroidal anti-inflammatory drugs (HR 5.50, 95% CI 3.56 to 8.51; P<0.001) were at increased risk of complications.
CONCLUSIONS: Specific clinical features (fever >38 degrees C, subacute course, large effusion or tamponade, and aspirin or NSAID failure) may be useful to identify higher risk of specific causal conditions and complications.

PMID 17502574  Circulation. 2007 May 29;115(21):2739-44. doi: 10.1161/・・・
著者: J Sagristà-Sauleda, J Mercé, G Permanyer-Miralda, J Soler-Soler
雑誌名: Am J Med. 2000 Aug 1;109(2):95-101.
Abstract/Text PURPOSE: To examine whether the size of the effusion, the presence of tamponade, and inflammatory signs are useful in determining the causes of moderate or severe pericardial effusions.
SUBJECTS AND METHODS: All echocardiograms performed at a general hospital between January 1990 and April 1996 were screened for pericardial effusion. Patients with moderate (echo-free space of 10 to 20 mm during diastole) or severe (echo-free space >20 mm) effusions were studied.
RESULTS: We identified 322 patients (166 [52%] men, mean [+/- SD] age 56 +/- 17 years [range 15 to 88 years]), 132 (41%) with moderate and 190 (59%) with severe pericardial effusion. The most frequent etiologic diagnoses were acute idiopathic pericarditis (n = 66 [20%]), iatrogenic effusions (n = 50 [16%]), cancer (n = 43 [13%]), and chronic idiopathic pericardial effusion (n = 29 [9%]). In 192 (60%) of the patients, the cause of the effusion was a known medical condition. In the 130 other patients, inflammatory signs were associated with acute idiopathic pericarditis (likelihood ratio = 5. 4, P < 0.001), severe effusions without inflammatory signs or tamponade were associated with chronic idiopathic pericardial effusion (likelihood ratio = 20, P < 0.001), and tamponade without inflammatory signs was associated with malignant effusions (likelihood ratio = 2.9, P < 0.01).
CONCLUSIONS: In many patients, pericardial effusions are due to a known underlying disease or condition. In patients without underlying diseases, inflammatory signs, the size of effusion, and the presence or absence of cardiac tamponade can be helpful in establishing cause.

PMID 10967149  Am J Med. 2000 Aug 1;109(2):95-101.
著者: G R Corey, P T Campbell, P Van Trigt, R T Kenney, C M O'Connor, K H Sheikh, J A Kisslo, T C Wall
雑誌名: Am J Med. 1993 Aug;95(2):209-13.
Abstract/Text PURPOSE: To determine the effectiveness of the preoperative evaluation and overall diagnostic efficacy of subxiphoid pericardial biopsy with fluid drainage in patients with new, large pericardial effusions.
DESIGN: A prospective interventional case series of consecutive patients admitted with new, large pericardial effusions.
PATIENTS AND METHODS: Fifty-seven of 75 consecutive patients admitted to a university tertiary-care center and a university-affiliated Veterans Administration Medical Center with new, large pericardial effusions were studied over a 20-month period. Each patient was assessed by a comprehensive preoperative evaluation followed by subxiphoid pericardiotomy. The patients' tissue and fluid samples were studied pathologically and cultured for aerobic and anaerobic bacteria, fungi, mycobacteria, mycoplasmas, and viruses.
RESULTS: A diagnosis was made in 53 (93%) patients. The principle diagnoses consisted of malignancy in 13 (23%) patients; viral infection in 8 (14%) patients; radiation-induced inflammation in 8 (14%) patients; collagen-vascular disease in 7 (12%) patients; and uremia in 7 (12%) patients. No diagnosis was made in four (7%) patients. A variety of unexpected organisms were cultured from either pericardial fluid or tissue: cytomegalovirus (three), Mycoplasma pneumoniae (two), herpes simplex virus (one), Mycobacterium avium-intracellulare (one), and Mycobacterium chelonei (one). The pericardial fluid yielded a diagnosis in 15 (26%) patients, 11 of whom had malignant effusions. The examination of pericardial tissue was useful in the diagnosis of 13 (23%) patients, 8 of whom had an infectious agent cultured. Of the 57 patients undergoing surgery, the combined diagnostic yield from both fluid and tissue was 19 patients (33%).
CONCLUSIONS: A systematic preoperative evaluation in conjunction with fluid and tissue analysis following subxiphoid pericardiotomy yields a diagnosis in the majority of patients with large pericardial effusions. This approach may also result in the culturing of "unusual" infectious organisms from pericardial tissue and fluid.

PMID 8356985  Am J Med. 1993 Aug;95(2):209-13.
著者: P T Campbell, J S Li, T C Wall, C M O'Connor, P Van Trigt, R T Kenney, O Melhus, G R Corey
雑誌名: Am J Med Sci. 1995 Apr;309(4):229-34.
Abstract/Text Cytomegalovirus (CMV) commonly infects both normal and immunocompromised hosts. Although it usually produces an asymptomatic infection to mild illness, CMV has the potential to significantly injure many different organs. Reports of CMV causing pericardial disease, however, are limited and documentation of infection by growth of the virus from tissue or fluid is rare. As part of a prospective trial of subxiphoid pericardial biopsy in 57 adult patients with large pericardial effusions, three culture-proven cases and one serologically confirmed case of CMV pericardial disease were discovered. Subsequently, CMV was grown from the pericardium of an infant with congenital heart disease. A review of the documented cases of CMV pericarditis is provided along with a discussion of the pathogenesis and significance of this perhaps not so uncommon disease.

PMID 7900747  Am J Med Sci. 1995 Apr;309(4):229-34.
著者: Massimo Imazio, Marco Bobbio, Enrico Cecchi, Daniela Demarie, Brunella Demichelis, Franco Pomari, Mauro Moratti, Gianni Gaschino, Massimo Giammaria, Aldo Ghisio, Riccardo Belli, Rita Trinchero
雑誌名: Circulation. 2005 Sep 27;112(13):2012-6. doi: 10.1161/CIRCULATIONAHA.105.542738.
Abstract/Text BACKGROUND: Colchicine is effective and safe for the treatment and prevention of recurrent pericarditis and might ultimately serve as the initial mode of treatment, especially in idiopathic cases. The aim of this work was to verify the safety and efficacy of colchicine as an adjunct to conventional therapy for the treatment of the first episode of acute pericarditis.
METHODS AND RESULTS: A prospective, randomized, open-label design was used. A total of 120 patients (mean age 56.9+/-18.8 years, 54 males) with a first episode of acute pericarditis (idiopathic, viral, postpericardiotomy syndromes, and connective tissue diseases) were randomly assigned to conventional treatment with aspirin (group I) or conventional treatment plus colchicine 1.0 to 2.0 mg for the first day and then 0.5 to 1.0 mg/d for 3 months (group II). Corticosteroid therapy was restricted to patients with aspirin contraindications or intolerance. The primary end point was recurrence rate. During the 2873 patient-month follow-up, colchicine significantly reduced the recurrence rate (recurrence rates at 18 months were, respectively, 10.7% versus 32.3%; P=0.004; number needed to treat=5) and symptom persistence at 72 hours (respectively, 11.7% versus 36.7%; P=0.003). After multivariate analysis, corticosteroid use (OR 4.30, 95% CI 1.21 to 15.25; P=0.024) was an independent risk factor for recurrences. Colchicine was discontinued in 5 cases (8.3%) because of diarrhea. No serious adverse effects were observed.
CONCLUSIONS: Colchicine plus conventional therapy led to a clinically important and statistically significant benefit over conventional treatment, decreasing the recurrence rate in patients with a first episode of acute pericarditis. Corticosteroid therapy given in the index attack can favor the occurrence of recurrences.

PMID 16186437  Circulation. 2005 Sep 27;112(13):2012-6. doi: 10.1161/C・・・
著者: Massimo Imazio, Antonio Brucato, Yehuda Adler, Giovanni Brambilla, Galit Artom, Enrico Cecchi, Giancarlo Palmieri, Rita Trinchero
雑誌名: Am J Cardiol. 2007 Sep 15;100(6):1026-8. doi: 10.1016/j.amjcard.2007.04.047. Epub 2007 Jul 6.
Abstract/Text After a systematic review of all publications on recurrent pericarditis from 1966 to 2006, we identified 8 major clinical series including a total of 230 patients with idiopathic recurrent pericarditis (mean age 46 years, men/women ratio: 0.9). After a mean follow-up of 61 months, the complication rate was 3.5% cardiac tamponade and 0% constrictive pericarditis and left ventricular dysfunction. The overall life prognosis is excellent in idiopathic recurrent pericarditis and complications are uncommon. In conclusion constrictive pericarditis was never reported despite numerous recurrences, and the risk is lower than in idiopathic acute pericarditis (approximately 1%). Thus, it is important to reassure patients on their prognosis, explaining the nature of the disease, and the likely course. Therapeutic choices should take into account of the overall good outcome of these patients, including less toxic agents.

PMID 17826391  Am J Cardiol. 2007 Sep 15;100(6):1026-8. doi: 10.1016/j・・・
著者: J Berman, C I Haffajee, J S Alpert
雑誌名: Am Heart J. 1981 Jun;101(6):750-3.
Abstract/Text We studied the efficacy of aspirin and indomethacin therapy in relieving the discomfort of postmyocardial infarction pericarditis (PMIP) in two studies: (1) a retrospective evaluation of patients with symptomatic PMIP during a 5-year period and (2) a prospective, randomized, single-blind comparison of aspirin and indomethacin in similar patients. In the retrospective study, 36 episodes of symptomatic PMIP in 34 patients were identified; in the prospective study, 25 episodes of PMIP in 24 patients occurred. Relief from the discomfort of PMIP was noted within 48 hours in almost all patients with either indomethacin or aspirin therapy. Minor gastrointestinal bleeding developed in two patients in the retrospective study and in two patients in the prospective study. In the retrospective study, mild discomfort of PMIP abated within 48 hours in five of eight patients who received either no treatment or minor analgesic therapy. Aspirin and indomethacin are equally efficacious in relieving the discomfort of PMIP.

PMID 7234652  Am Heart J. 1981 Jun;101(6):750-3.
著者: Y Adler, Y Finkelstein, J Guindo, A Rodriguez de la Serna, Y Shoenfeld, A Bayes-Genis, A Sagie, A Bayes de Luna, D H Spodick
雑誌名: Circulation. 1998 Jun 2;97(21):2183-5.
Abstract/Text BACKGROUND: The most troublesome complication of acute pericarditis is recurrent episodes of pericardial inflammation, occurring in 15% to 32% of cases. The cause of the recurrence is usually unknown, although in some cases it may be traced to viral infection or may be a consequence of coronary artery bypass grafting. The optimal method for prevention has not been fully established; accepted modalities include nonsteroidal anti-inflammatory drugs, corticosteroids, immunosuppressive agents, and pericardiectomy.
METHODS AND RESULTS: Based on the proven efficacy of colchicine therapy for familial Mediterranean fever (recurrent polyserositis), several small studies have used colchicine successfully to prevent recurrence of acute pericarditis after failure of conventional treatment. Recently, we reported the results from the largest multicenter international study on 51 patients who were treated with colchicine to prevent further relapses and who were followed up for < or = 10 years.
CONCLUSIONS: In light of new trial data that have accumulated in the past decade, we review the evidence for the efficacy and safety of colchicine for the prevention of recurrent episodes of pericarditis. Clinical and personal experience shows that colchicine may be an extremely promising adjunct to conventional treatment and may ultimately serve as the initial mode of treatment, especially in idiopathic cases.

PMID 9626180  Circulation. 1998 Jun 2;97(21):2183-5.
著者: Massimo Imazio, Marco Bobbio, Enrico Cecchi, Daniela Demarie, Franco Pomari, Mauro Moratti, Aldo Ghisio, Riccardo Belli, Rita Trinchero
雑誌名: Arch Intern Med. 2005 Sep 26;165(17):1987-91. doi: 10.1001/archinte.165.17.1987.
Abstract/Text BACKGROUND: Colchicine seems to be a good drug for treating recurrences of pericarditis after conventional treatment failure, but no clinical trial has tested the effects of colchicine as first-line drug for the treatment of the first recurrence of pericarditis.
METHODS: A prospective, randomized, open-label design was used to investigate the safety and efficacy of colchicine therapy as adjunct to conventional therapy for the first episode of recurrent pericarditis. Eighty-four consecutive patients with a first episode of recurrent pericarditis were randomly assigned to receive conventional treatment with aspirin alone or conventional treatment plus colchicine (1.0-2.0 mg the first day and then 0.5-1.0 mg/d for 6 months). When aspirin was contraindicated, prednisone (1.0-1.5 mg/kg daily) was given for 1 month and then was gradually tapered. The primary end point was the recurrence rate. Intention-to-treat analyses were performed by treatment group.
RESULTS: During 1682 patient-months (mean follow-up, 20 months), treatment with colchicine significantly decreased the recurrence rate (actuarial rates at 18 months were 24.0% vs 50.6%; P = .02; number needed to treat = 4.0; 95% confidence interval 2.5-7.1) and symptom persistence at 72 hours (10% vs 31%; P = .03). In multivariate analysis, previous corticosteroid use was an independent risk factor for further recurrences (odds ratio, 2.89; 95% confidence interval, 1.10-8.26; P = .04). No serious adverse effects were observed.
CONCLUSION: Colchicine therapy led to a clinically important and statistically significant benefit over conventional treatment, decreasing the recurrence rate in patients with a first episode of recurrent pericarditis.

PMID 16186468  Arch Intern Med. 2005 Sep 26;165(17):1987-91. doi: 10.1・・・
著者: Massimo Imazio, Antonio Brucato, Roberto Cemin, Stefania Ferrua, Stefano Maggiolini, Federico Beqaraj, Daniela Demarie, Davide Forno, Silvia Ferro, Silvia Maestroni, Riccardo Belli, Rita Trinchero, David H Spodick, Yehuda Adler, ICAP Investigators
雑誌名: N Engl J Med. 2013 Oct 17;369(16):1522-8. doi: 10.1056/NEJMoa1208536. Epub 2013 Aug 31.
Abstract/Text BACKGROUND: Colchicine is effective for the treatment of recurrent pericarditis. However, conclusive data are lacking regarding the use of colchicine during a first attack of acute pericarditis and in the prevention of recurrent symptoms.
METHODS: In a multicenter, double-blind trial, eligible adults with acute pericarditis were randomly assigned to receive either colchicine (at a dose of 0.5 mg twice daily for 3 months for patients weighing >70 kg or 0.5 mg once daily for patients weighing ≤70 kg) or placebo in addition to conventional antiinflammatory therapy with aspirin or ibuprofen. The primary study outcome was incessant or recurrent pericarditis.
RESULTS: A total of 240 patients were enrolled, and 120 were randomly assigned to each of the two study groups. The primary outcome occurred in 20 patients (16.7%) in the colchicine group and 45 patients (37.5%) in the placebo group (relative risk reduction in the colchicine group, 0.56; 95% confidence interval, 0.30 to 0.72; number needed to treat, 4; P<0.001). Colchicine reduced the rate of symptom persistence at 72 hours (19.2% vs. 40.0%, P=0.001), the number of recurrences per patient (0.21 vs. 0.52, P=0.001), and the hospitalization rate (5.0% vs. 14.2%, P=0.02). Colchicine also improved the remission rate at 1 week (85.0% vs. 58.3%, P<0.001). Overall adverse effects and rates of study-drug discontinuation were similar in the two study groups. No serious adverse events were observed.
CONCLUSIONS: In patients with acute pericarditis, colchicine, when added to conventional antiinflammatory therapy, significantly reduced the rate of incessant or recurrent pericarditis. (Funded by former Azienda Sanitaria Locale 3 of Turin [now Azienda Sanitaria Locale 2] and Acarpia; ICAP ClinicalTrials.gov number, NCT00128453.).

PMID 23992557  N Engl J Med. 2013 Oct 17;369(16):1522-8. doi: 10.1056/・・・
著者: B M Mayosi, M Ntsekhe, J A Volmink, P J Commerford
雑誌名: Cochrane Database Syst Rev. 2002;(4):CD000526. doi: 10.1002/14651858.CD000526.
Abstract/Text BACKGROUND: Tuberculous pericarditis - tuberculosis infection of the pericardial membrane (pericardium) covering the heart - is becoming more common. The infection can result in fluid around the heart or fibrosis of the pericardium, which can be fatal.
OBJECTIVES: In people with tuberculous pericarditis, to evaluate the effects on death, life-threatening conditions, and persistent disability of: (1) 6-month antituberculous drug regimens compared with regimens of 9 months or more; (2) corticosteroids; (3) pericardial drainage; and (4) pericardiectomy.
SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group trials register (June 2002), the Cochrane Controlled Trials Register (Issue 2, 2002), MEDLINE (1966 to June 2002), EMBASE (1980 to May 2002), and checked the reference lists of existing reviews. We also contacted organizations and individuals working in the field.
SELECTION CRITERIA: Randomized and quasi-randomized controlled trials of treatments for tuberculous pericarditis.
DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Meta-analysis using fixed effects models calculated summary statistics, provided there was no statistically significant heterogeneity, and expressed results as relative risk. Study authors were contacted for additional information.
MAIN RESULTS: Four trials met the inclusion criteria, with a total of 469 participants. Treatments tested were adjuvant steroids and surgical drainage. Two trials with a total of 383 participants tested adjuvant steroids in participants with suspected tuberculous pericarditis in the pre-HIV era. Fewer participants died in the intervention group, but numbers were small (relative risk [RR] 0.65; 95% confidence interval [CI] 0.36 to 1.16, n = 350). One small trial tested steroids in HIV positive participants with effusion showed a similar pattern (RR 0.50; 95% CI 0.19 to 1.28, n = 58). One trial examined open surgical drainage compared with conservative management, and showed surgery relieved cardiac tamponade.
REVIEWER'S CONCLUSIONS: Steroids could have important clinical benefits, but the trials published to date are too small to demonstrate an effect. This requires large placebo controlled trials. Subgroup analysis could explore whether effusion or fibrosis modify the effects. Therapeutic pericardiocentesis under local anaesthesia and pericardiectomy also require further evaluation.

PMID 12519546  Cochrane Database Syst Rev. 2002;(4):CD000526. doi: 10.・・・
著者: Massimo Imazio, Antonio Brucato, Davide Cumetti, Giovanni Brambilla, Brunella Demichelis, Silvia Ferro, Silvia Maestroni, Enrico Cecchi, Riccardo Belli, Giancarlo Palmieri, Rita Trinchero
雑誌名: Circulation. 2008 Aug 5;118(6):667-71. doi: 10.1161/CIRCULATIONAHA.107.761064. Epub 2008 Jul 21.
Abstract/Text BACKGROUND: Corticosteroid use is widespread in recurrent pericarditis, even if rarely indicated, and high doses (eg, prednisone 1.0 to 1.5 mg . kg(-1) . d(-1)) are generally recommended, although only weak evidence supports their use with possible severe side effects. The aim of this work was to compare side effects, recurrences and other complications, and hospitalizations of a low- versus high-dose regimen of prednisone for recurrent pericarditis.
METHODS AND RESULTS: A retrospective review of all cases of recurrent pericarditis treated with corticosteroids according to different regimens from January 1996 to June 2004 was performed in 2 Italian referral centers. One hundred patients with recurrent pericarditis (mean age, 50.1+/-15.8 years; 57 females) were included in the study; 49 patients (mean age, 47.5+/-16.0; 25 females) were treated with low doses of prednisone (0.2 to 0.5 mg . kg(-1) . d(-1)), and 51 patients (mean age, 52.6+/-15.3; 32 females) were treated with prednisone 1.0 mg . kg(-1) . d(-1). Baseline demographic and clinical characteristics were well balanced across the groups. Each initial dose was maintained for 4 weeks and then slowly tapered. After adjustment for potential confounders (age, female gender, nonidiopathic origin), only high doses of prednisone were associated with severe side effects, recurrences, and hospitalizations (hazard ratio, 3.61; 95% confidence interval, 1.96 to 6.63; P<0.001).
CONCLUSIONS: Use of higher doses of prednisone (1.0 mg . kg(-1) . d(-1)) for recurrent pericarditis is associated with more side effects, recurrences, and hospitalizations. Lower doses of prednisone should be considered when corticosteroids are needed to treat pericarditis.

PMID 18645054  Circulation. 2008 Aug 5;118(6):667-71. doi: 10.1161/CIR・・・
著者: Antonio Brucato, Massimo Imazio, Marco Gattorno, George Lazaros, Silvia Maestroni, Mara Carraro, Martina Finetti, Davide Cumetti, Alessandra Carobbio, Nicolino Ruperto, Renzo Marcolongo, Monia Lorini, Alessandro Rimini, Anna Valenti, Gian Luca Erre, Maria Pia Sormani, Riccardo Belli, Fiorenzo Gaita, Alberto Martini
雑誌名: JAMA. 2016 Nov 8;316(18):1906-1912. doi: 10.1001/jama.2016.15826.
Abstract/Text Importance: Anakinra, an interleukin 1β recombinant receptor antagonist, may have potential to treat colchicine-resistant and corticosteroid-dependent recurrent pericarditis.
Objective: To determine the efficacy of anakinra for colchicine-resistant and corticosteroid-dependent recurrent pericarditis.
Design, Setting, and Participants: The Anakinra-Treatment of Recurrent Idiopathic Pericarditis (AIRTRIP) double-blind, placebo-controlled, randomized withdrawal trial (open label with anakinra followed by a double-blind withdrawal step with anakinra or placebo until recurrent pericarditis occurred) conducted among 21 consecutive patients enrolled at 3 Italian referral centers between June and November 2014 (end of follow-up, October 2015). Included patients had recurrent pericarditis (with ≥3 previous recurrences), elevation of C-reactive protein, colchicine resistance, and corticosteroid dependence.
Interventions: Anakinra was administered at 2 mg/kg per day, up to 100 mg, for 2 months, then patients who responded with resolution of pericarditis were randomized to continue anakinra (n = 11) or switch to placebo (n = 10) for 6 months or until a pericarditis recurrence.
Main Outcomes and Measures: The primary outcomes were recurrent pericarditis and time to recurrence after randomization.
Results: Eleven patients (7 female) randomized to anakinra had a mean age of 46.5 (SD, 16.3) years; 10 patients (7 female) randomized to placebo had a mean age of 44 (SD, 12.5) years. All patients were followed up for 12 months. Median follow-up was 14 (range, 12-17) months. Recurrent pericarditis occurred in 9 of 10 patients (90%; incidence rate, 2.06% of patients per year) assigned to placebo and 2 of 11 patients (18.2%; incidence rate, 0.11% of patients per year) assigned to anakinra, for an incidence rate difference of -1.95% (95% CI, -3.3% to -0.6%). Median flare-free survival (time to flare) was 72 (interquartile range, 64-150) days after randomization in the placebo group and was not reached in the anakinra group (P <.001). During anakinra treatment, 20 of 21 patients (95.2%) experienced transient local skin reactions: 1 (4.8%) herpes zoster, 3 (14.3%) transaminase elevation, and 1 (4.8%) ischemic optic neuropathy. No patient permanently discontinued the active drug. No adverse events occurred during placebo treatment.
Conclusion and Relevance: In this preliminary study of patients with recurrent pericarditis with colchicine resistance and corticosteroid dependence, the use of anakinra compared with placebo reduced the risk of recurrence over a median of 14 months. Larger studies are needed to replicate these findings as well as to assess safety and longer-term efficacy.
Trial Registration: clinicaltrials.gov Identifier: NCT02219828.

PMID 27825009  JAMA. 2016 Nov 8;316(18):1906-1912. doi: 10.1001/jama.2・・・
著者: Karim Abdur Rehman, Jorge Betancor, Bo Xu, Arnav Kumar, Carlos Godoy Rivas, Kimi Sato, Leslie P Wong, Craig R Asher, Allan L Klein
雑誌名: Clin Cardiol. 2017 Oct;40(10):839-846. doi: 10.1002/clc.22770. Epub 2017 Sep 5.
Abstract/Text A rising prevalence of end-stage renal disease (ESRD) has led to a rise in ESRD-related pericardial syndromes, calling for a better understanding of its pathophysiology, diagnoses, and management. Uremic pericarditis, the most common manifestation of uremic pericardial disease, is a contemporary problem that calls for intensive hemodialysis, anti-inflammatories, and often, drainage of large inflammatory pericardial effusions. Likewise, asymptomatic pericardial effusions can become large and impact the hemodynamics of patients on chronic hemodialysis. Constrictive pericarditis is also well documented in this population, ultimately resulting in pericardiectomy for definitive treatment. The management of pericardial diseases in ESRD patients involves internists, cardiologists, and nephrologists. Current guidelines lack clarity with respect to the management of pericardial processes in the ESRD population. Our review aims to describe the etiology, classification, clinical manifestations, diagnostic imaging tools, and treatment options of pericardial diseases in this population.

© 2017 Wiley Periodicals, Inc.
PMID 28873222  Clin Cardiol. 2017 Oct;40(10):839-846. doi: 10.1002/clc・・・
著者: Yassamine Bentata, F Hamdi, A Chemlal, I Haddiya, N Ismaili, N El Ouafi
雑誌名: Am J Emerg Med. 2018 Mar;36(3):464-466. doi: 10.1016/j.ajem.2017.11.048. Epub 2017 Nov 21.
Abstract/Text The prevalence of uremic pericarditis (UP) used to range from 3% to 41%. More recently, it has decreased to about 5%-20% and to <5% in the last decades, as hemodialysis techniques have become widely used and dialysis quality improved. The objective of this work is to determine the initial clinical picture and the prognosis of patients presenting End Stage Renal Disease (ESRD) with UP.
MATERIALS: This is a retrospective study (May 2015-September 2017). Inclusion criteria targeted patients who had uremic pericarditis defined as pericarditis occurring in a patient with ESRD before initiation of renal replacement therapy, or within eight weeks of its initiation.
RESULTS: 16 patients met the inclusion criteria. The median age of patients was 54 [24, 71] years and 56.2% were male. Pericardial effusion was small, moderate and large in 31.2%, 37.6% and 31.2% of cases respectively. One pericardiocentesis was performed in view of a clinical picture of impending cardiac tamponade and three pericardial drainages were performed given presentation of tamponade. Hemodialysis was initiated for all the patients and continued for 2 to 3weeks until complete regression of the pericardial effusion. The mean number of dialysis sessions was 11±3.5. One patient died of septic shock that developed three weeks after diagnosis of uremic pericarditis.
CONCLUSION: UP is considered a rare but fatal complication of ESRD because of the risk of tamponade and its prognosis remains dependent on early diagnosis and adequate treatment of ESRD.

Copyright © 2017 Elsevier Inc. All rights reserved.
PMID 29248269  Am J Emerg Med. 2018 Mar;36(3):464-466. doi: 10.1016/j.・・・
著者: Martin A Alpert, Mark D Ravenscraft
雑誌名: Am J Med Sci. 2003 Apr;325(4):228-36.
Abstract/Text Pericardial involvement in end-stage renal disease (ESRD) is manifested most commonly as acute uremic or dialysis pericarditis and infrequently as chronic constrictive pericarditis. The causes of uremic and dialysis pericarditis remain uncertain. The clinical and laboratory manifestations of acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis in patients with chronic renal failure are similar to those observed in nonuremic patients with similar pericardial involvement, except that chest pain occurs less frequently in those with ESRD. Therapeutic interventions for acute uremic or dialysis pericarditis with or without pericardial effusion include intensive hemodialysis, pericardiocentesis (infrequently used), pericardiostomy with or without instillation of intrapericardial glucocorticoids, pericardial window, and pericardiectomy. Chronic constrictive pericarditis is treated with pericardiectomy.

PMID 12695728  Am J Med Sci. 2003 Apr;325(4):228-36.
著者: Gal Markel, Massimo Imazio, Antonio Brucato, Yehuda Adler
雑誌名: Isr Med Assoc J. 2008 Jan;10(1):69-72.
Abstract/Text The most troublesome complication of acute pericarditis is recurrent episodes of pericardial inflammation, which occur in 15-32% of cases. It was recently found that viral infection has a major role, but in many cases the cause is unknown. The optimal method for prevention has not been fully established; accepted modalities include non-steroidal anti-inflammatory drugs, corticosteroids, immunosuppressive agents, and pericardiectomy. Based on the proven efficacy of colchicine in familial Mediterranean fever, several small and large-scale international clinical trials have shown the beneficial effect of colchicine therapy in preventing recurrent pericarditis. Indeed, colchicine-treated patients consistently display significantly fewer recurrences, longer symptom-free periods, and even when attacks occur they are weaker and shorter in nature. It was also found that pretreatment with corticosteroids substantially attenuates the efficacy of colchicine, as evidenced by significantly more recurrence episodes and longer therapy periods. Colchicine is a safe and effective modality for the treatment and prevention of recurrent pericarditis, especially as an adjunct to other modalities, since it provides a sustained benefit superior to all current modalities. The safety profile seems superior to other drugs such as corticosteroids and immunosuppressive drugs.

PMID 18300579  Isr Med Assoc J. 2008 Jan;10(1):69-72.
著者: J Cameron, S N Oesterle, J C Baldwin, E W Hancock
雑誌名: Am Heart J. 1987 Feb;113(2 Pt 1):354-60.
Abstract/Text Ninety-five consecutive patients with constrictive pericarditis that was documented at the time of surgery during 1970 to 1985 were reviewed. The etiologies included idiopathic (42%), postradiotherapy (31%), post-cardiac surgery (11%), postinfective (6%), connective tissue disease-related (4%), neoplastic (3%) uremic (2%), and sarcoidosis (1%). Post-cardiac surgery etiology was seen only after 1980, but constituted 29% of cases during 1980-1985. Postradiotherapy etiology occurred with equal incidence in 1980-1985 and in 1970-1980, but the interval from radiotherapy to presentation with constrictive pericarditis was longer in the more recent period (11 vs 4.75 years). Effusive constrictive pericarditis occurred in 24% overall with similar prevalence in all of the etiologic groups except the postsurgical cases, which were caused by noneffusive fibrous constrictive pericarditis in all instances. Operative mortality was 12% overall: It was lower in the idiopathic group (8%) and higher in the postradiotherapy group (21%). Thus postradiotherapy constrictive pericarditis continues to occur despite technical changes aimed at reducing its likelihood, but recent cases have a longer latent period: and postsurgical constrictive pericarditis has emerged as an important etiology.

PMID 3812191  Am Heart J. 1987 Feb;113(2 Pt 1):354-60.
著者: L H Ling, J K Oh, H V Schaff, G K Danielson, D W Mahoney, J B Seward, A J Tajik
雑誌名: Circulation. 1999 Sep 28;100(13):1380-6.
Abstract/Text BACKGROUND: The clinical spectrum of constrictive pericarditis (CP) has been affected by a change in incidence of etiological factors. We sought to determine the impact of these changes on the outcome of pericardiectomy.
METHODS AND RESULTS: The contemporary spectrum of CP in 135 patients (76% male) evaluated at the Mayo Clinic from 1985 to 1995 was compared with that of a historic cohort. Notable trends were an increasing frequency of CP due to cardiac surgery and mediastinal radiation and presentation in older patients (median age, 61 versus 45 years). Perioperative mortality decreased (6% versus 14%, P = 0.011), but late survival was inferior to that of an age- and sex-matched US population (57+/-8% at 10 years). The long-term outcome was predicted independently by 3 variables in stepwise logistic regression analyses: (1) age, (2) NYHA class, and most powerfully, (3) a postradiation cause. Of 90 late survivors in whom functional class could be determined, functional status had improved markedly (2.6+/-0.7 at baseline versus 1.5+/-0.8 at latest follow-up [P<0.0001]), with 83% being free of clinical symptoms.
CONCLUSIONS: The evolving profile of CP, with increasingly older patients and those with radiation-induced disease in the past decade, significantly affects postoperative prognosis. Long-term results of pericardiectomy are disappointing for some patient groups, especially those with radiation-induced CP. By contrast, surgery alleviates or improves symptoms in the majority of late survivors.

PMID 10500037  Circulation. 1999 Sep 28;100(13):1380-6.
著者: Timothy J George, George J Arnaoutakis, Claude A Beaty, Arman Kilic, William A Baumgartner, John V Conte
雑誌名: Ann Thorac Surg. 2012 Aug;94(2):445-51. doi: 10.1016/j.athoracsur.2012.03.079. Epub 2012 May 22.
Abstract/Text BACKGROUND: The leading causes of constrictive pericarditis have changed over time leading to a commensurate change in the indications and complexity of surgical pericardiectomy. We evaluated our single-center experience to define the etiologies, risk factors, and outcomes of pericardiectomy in a modern cohort.
METHODS: We retrospectively reviewed our institutional database for all patients who underwent total or partial pericardiectomy. Demographic, comorbid, operative, and outcome data were evaluated. Survival was assessed by the Kaplan-Meier method. Multivariable Cox proportional hazards regression models examined risk factors for mortality.
RESULTS: From 1995 to 2010, 98 adults underwent pericardiectomy for constrictive disease. The most common etiologies were idiopathic (n=44), postoperative (n=30), and post radiation (n=17). Total pericardiectomy was performed in 94 cases, most commonly through a sternotomy (n=93). Thirty-three cases were redo sternotomies, 34 underwent a concomitant procedure, and 34 required cardiopulmonary bypass. Overall in-hospital, 1-year, 5-year, and 10-year survival rates were 92.9%, 82.5%, 64.3%, and 49.2%, respectively. Survival differed sharply by etiology with idiopathic, postoperative, and post-radiation 5-year survivals of 79.8%, 55.9%, and 11.0%, respectively (p<0.001). On multivariable analysis, only the need for cardiopulmonary bypass (hazard ratio [HR]: 21.2, p=0.02) was predictive of 30-day mortality while post-radiation etiology (HR: 3.19, p=0.02) and hypoalbuminemia (HR: 0.57, p=0.03) were associated with increased 10-year mortality.
CONCLUSIONS: Although survival varies significantly by etiology, pericardiectomy continues to be a safe operation for constrictive pericarditis. Post-radiation pericarditis and hypoalbuminemia are significant risk factors for decreased long-term survival.

Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
PMID 22621875  Ann Thorac Surg. 2012 Aug;94(2):445-51. doi: 10.1016/j.・・・
著者: Stefan C Bertog, Senthil K Thambidorai, Kapil Parakh, Paul Schoenhagen, Volkan Ozduran, Penny L Houghtaling, Bruce W Lytle, Eugene H Blackstone, Michael S Lauer, Allan L Klein
雑誌名: J Am Coll Cardiol. 2004 Apr 21;43(8):1445-52. doi: 10.1016/j.jacc.2003.11.048.
Abstract/Text OBJECTIVES: We sought to determine the association of etiology of constrictive pericarditis (CP), pericardial calcification (CA), and other clinical variables with long-term survival after pericardiectomy.
BACKGROUND: Constrictive pericarditis is the result of a spectrum of primary cardiac and noncardiac conditions. Few data exist on the cause-specific survival after pericardiectomy. The impact of CA on survival is unclear.
METHODS: A total of 163 patients who underwent pericardiectomy for CP over a 24-year period at a single surgical center were studied. Constrictive pericarditis was confirmed by the surgical report. Vital status was obtained from the Social Security Death Index.
RESULTS: Etiology of CP was idiopathic in 75 patients (46%), prior cardiac surgery in 60 patients (37%), radiation treatment in 15 patients (9%), and miscellaneous in 13 patients (8%). Median follow-up among survivors was 6.9 years (range 0.8 to 24.5 years), during which time there were 61 deaths. Perioperative mortality was 6%. Idiopathic CP had the best prognosis (7-year Kaplan-Meier survival: 88%, 95% confidence interval [CI] 76% to 94%) followed by postsurgical (66%, 95% CI 52% to 78%) and postradiation CP (27%, 95% CI 9% to 58%). In bootstrap-validated proportional hazards analyses, predictors of poor overall survival were prior radiation, worse renal function, higher pulmonary artery systolic pressure (PAP), abnormal left ventricular (LV) systolic function, lower serum sodium level, and older age. Pericardial calcification had no impact on survival.
CONCLUSIONS: Long-term survival after pericardiectomy for CP is related to underlying etiology, LV systolic function, renal function, serum sodium, and PAP. The relatively good survival with idiopathic CP emphasizes the safety of pericardiectomy in this subgroup.

PMID 15093882  J Am Coll Cardiol. 2004 Apr 21;43(8):1445-52. doi: 10.1・・・
著者: Gábor Szabó, Bastian Schmack, Cem Bulut, Pál Soós, Alexander Weymann, Susanne Stadtfeld, Matthias Karck
雑誌名: Eur J Cardiothorac Surg. 2013 Dec;44(6):1023-8; discussion 1028. doi: 10.1093/ejcts/ezt138. Epub 2013 Jun 12.
Abstract/Text OBJECTIVES: Constrictive pericarditis is the result of a spectrum of primary cardiac and non-cardiac conditions. Few data exist on the preoperative risk specific to survival after pericardiectomy. This study was designed to compare the association of aetiology of constrictive pericarditis and other clinical variables, with long-term survival after total pericardiectomy.
METHODS: A total of 89 patients were studied, who underwent pericardiectomy for constrictive pericarditis at a single surgical centre between 1988 and 2012. Constrictive pericarditis was confirmed by the surgical report. Demographic, pre-, intra- and postoperative data and long-term outcome were investigated. Survival was assessed by the Kaplan-Meier method.
RESULTS: Aetiology of constrictive pericarditis was idiopathic in 49 patients (55%), prior cardiac surgery in 21 patients (23.6%), tuberculosis in 5 patients (5.6%), radiation treatment in 5 (5.6%), uraemia in 4 (4.5%), inflammation in 3 (3.5%) myocardial infarction in 2 (2.2%), and perioperative mortality was 7%. Seventy-five percent of patients were in New York Heart Association (NYHA) class III-IV, which status significantly improved in long-term survivors (95% in NYHA I-II). Idiopathic constrictive pericarditis had the best prognosis (5-year Kaplan-Meier survival: 81%) followed by post-surgical (50%) and post-radiation pericarditis (no survivors after 5 years). Tuberculosis, myocardial infarction and uraemia have survival rates comparable with idiopathic aetiology. In addition, preoperative NYHA class IV was associated with significantly lower long-term survival.
CONCLUSIONS: Long-term survival after pericardiectomy for constrictive pericarditis is related to underlying aetiology and overall clinical condition. The relatively good survival with idiopathic constrictive pericarditis emphasizes the safety of pericardiectomy in this subgroup.

PMID 23761416  Eur J Cardiothorac Surg. 2013 Dec;44(6):1023-8; discuss・・・
著者: John H Haley, A Jamil Tajik, Gordon K Danielson, Hartzell V Schaff, Sharon L Mulvagh, Jae K Oh
雑誌名: J Am Coll Cardiol. 2004 Jan 21;43(2):271-5.
Abstract/Text OBJECTIVES: This study was designed to elucidate the causes and natural history of transient constrictive pericarditis (CP).
BACKGROUND: In some patients with acute CP, the symptoms and constrictive physiologic features resolve with medical therapy alone, a phenomenon that has been labeled "transient constrictive pericarditis." No large studies have examined the causes or natural history of transient CP.
METHOD: Review of the Mayo Clinic echocardiogram database identified 212 patients who had echocardiographic findings of CP from 1988 through 1999. Demographic, clinical, and echocardiographic findings were identified in all patients. In 36 of these patients, follow-up echocardiograms showed resolution of the constrictive hemodynamics without pericardiectomy.
RESULTS: The average age of the patients was 49 +/- 21 years, and 72% were men. The causes for the CP were diverse, the most common being prior cardiovascular surgery (25%). In a subset of 22 patients who were followed serially during the course of their illness, resolution of the constrictive physiologic features occurred at an average of 8.3 weeks after diagnosis.
CONCLUSIONS: A subset of patients with CP experience resolution of the disorder without requiring pericardiectomy.

PMID 14736448  J Am Coll Cardiol. 2004 Jan 21;43(2):271-5.
著者: Ujjwal K Chowdhury, Ganapathy K Subramaniam, A Sampath Kumar, Balram Airan, Rajvir Singh, Sachin Talwar, Sandeep Seth, Pankaj K Mishra, Kizakke K Pradeep, Siddhartha Sathia, Panangipalli Venugopal
雑誌名: Ann Thorac Surg. 2006 Feb;81(2):522-9. doi: 10.1016/j.athoracsur.2005.08.009.
Abstract/Text BACKGROUND: This study was designed to compare the outcomes after total versus partial pericardiectomy clinically, echocardiographically, and hemodynamically.
METHODS: Three hundred ninety-five patients undergoing pericardiectomy for constrictive pericarditis between January 1985 and December 2004 were studied. Age was 10 months to 71 years (mean, 25.1 +/- 13.4 years). Three hundred thirty-eight patients (85.6%) underwent total pericardiectomy (group I), and 57 patients (14.4%) underwent partial pericardiectomy (group II).
RESULTS: Operative and late mortality rates were 7.6% and 4.9%, respectively. Preoperative high right atrial pressure, hyperbilirubinemia, renal dysfunction, atrial fibrillation, pericardial calcification, thoracotomy approach, and partial pericardiectomy were significant risk factors for death. The risk of death was 4.5 times higher (95% confidence interval: 2.05 to 9.75) in patients undergoing partial pericardiectomy. At a mean follow-up of 17.9 +/- 0.3 years (95% confidence interval: 17.3 to 18.6), actuarial survival was 83.8% +/- 0.04% in group I and 73.9% +/- 0.06% in group II (p = 0.004). At their last follow-up, 96.3% survivors of group I and 79.1% survivors of group II were in New York Heart Association class I/II (p < 0.001).
CONCLUSIONS: Total pericardiectomy is associated with lower perioperative and late mortality, and confers significant long-term advantage by providing superior hemodynamics that appear to be independent of the etiology of constrictive pericarditis.

PMID 16427843  Ann Thorac Surg. 2006 Feb;81(2):522-9. doi: 10.1016/j.a・・・
著者: P A DeValeria, W A Baumgartner, A S Casale, P S Greene, D E Cameron, T J Gardner, V L Gott, L Watkins, B A Reitz
雑誌名: Ann Thorac Surg. 1991 Aug;52(2):219-24.
Abstract/Text A retrospective analysis of the records of 60 patients who underwent pericardiectomy over a 10-year period (1980 to 1990) at The Johns Hopkins Hospital was performed. Indications for operation were effusive disease in 24 patients and constriction in 36 patients. Six patients (10%) with pericardial effusion had pain as the primary symptom necessitating intervention. The operative approach for pericardiectomy was median sternotomy in 52 patients (4 patients required cardiopulmonary bypass) and left anterior thoracotomy in 8 patients. Nine patients (5 with constriction and 4 with effusion) with a prior limited pericardial procedure required formal pericardiectomy. The operative mortality rate for pericardial effusion and constriction was 4.2% and 5.6%, respectively. Follow-up (median follow-up, 56.9 +/- 38.2 months) was obtained on 56 patients (93.3%). Actuarial survival at 1 year, 5 years, and 10 years for all patients was 82.1% +/- 5.1%, 71.7% +/- 6.7%, and 59.8% +/- 12.2%, respectively. A Cox proportional hazards regression analysis was performed using 20 clinical variables. A history of malignancy, previous pericardial procedure, and preoperative New York Heart Association class IV were found to be predictors of poor survival. All patients who underwent operation primarily for effusion with associated pain are alive and have improved functional capacity without steroid use. We conclude that pericardiectomy can be performed with low mortality and can result in good long-term survival and improved functional capacity. Patients who are seen primarily with pain refractory to steroid therapy can be relieved of symptoms with operation.

PMID 1863142  Ann Thorac Surg. 1991 Aug;52(2):219-24.
著者: Alireza A Ghavidel, Maziar Gholampour, Majid Kyavar, Yalda Mirmesdagh, Mohammad-Bagher Tabatabaie
雑誌名: Tex Heart Inst J. 2012;39(2):199-205.
Abstract/Text We reviewed the records of 45 patients (mean age, 46.6 ± 14.9 yr; range, 21-84 yr) with a diagnosis of constrictive pericarditis who had undergone pericardiectomy from 1994 through 2006. Preoperatively, 2 of the patients (4.4%) were in New York Heart Association (NYHA) functional class I, 20 (44.4%) in class II, 22 (48.9%) in class III, and 1 (2.2%) in class IV. Pericardial calcification was detected in 20% of plain chest radiographs. Constrictive pericarditis was caused by tuberculosis in 22.2%, chronic renal failure in 8.9%, a history of sternotomy in 4.4%, and malignancy in 4.4%. The cause was idiopathic in 60% of the patients. Low-output state was the most common postoperative problem (22.2%). The mean follow-up period was 40 ± 18 months (range, 3-144 mo). Three months postoperatively, only 1 of 43 available patients (2.3%) was in NYHA class III, while the rest were in class I (36 patients; 83.7%) or II (6 patients; 14%). The overall mortality rate was 4.4%: 1 patient with tuberculosis died of respiratory insufficiency while hospitalized, and 1 died of metastatic adenocarcinoma during follow-up. Our results show that pericardiectomy remains an effective procedure in the treatment of constrictive pericarditis. Tuberculosis is still an important cause of constrictive pericarditis in Iran, despite intensive vaccination and use of antitubercular drugs.

PMID 22740731  Tex Heart Inst J. 2012;39(2):199-205.

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