Our mission is to become a worldwide reference for education in the field for all professionals involved in the process to disseminate knowledge & skills of Acute Cardiovascular Care.
Our mission is to promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular imaging in Europe.
Our mission is to promote excellence in research, practice, education and policy in cardiovascular health, primary and secondary prevention.
Our mission is to reduce the burden of cardiovascular disease in Europe through percutaneous cardiovascular interventions.
Our mission is to improve the quality of life of the population by reducing the impact of cardiac rhythm disturbances and reduce sudden cardiac death.
Our mission is to improve quality of life and longevity, through better prevention, diagnosis and treatment of heart failure, including the establishment of networks for its management, education and research.
The ESC Working Groups' goal is to stimulate and disseminate scientific knowledge in different fields of cardiology.
The ESC Councils' goal is to share knowledge among medical professionals practising in specific cardiology domains.
OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Summary of the paper
In the February issue of the Annals of Internal Medicine, Meurin and the colleagues from the French Society of Cardiology  have published results of their randomized trial on the NSAIDs Treatment for Postoperative Pericardial Effusion, performed in 5 French postoperative cardiac rehabilitation centres. They evaluated 196 patients at high risk for tamponade because of moderate to large persistent pericardial effusion (grade 2, 3, or 4 on a scale of 0 to 4, as measured by echocardiography) more than 7 days after cardiac surgery. The patients were randomly assigned at each site in blocks of 4 to diclofenac, 50 mg, or placebo twice daily for 14 days. The main end point was change in effusion grade after 14 days of treatment. Secondary end points included frequency of late cardiac tamponade. The initial mean pericardial effusion grade was 2.58 (SD, 0.73) for the placebo group and 2.75 (SD, 0.81) for the diclofenac group. The 2 groups showed similar mean decreases from baseline after treatment (-1.08 grades [SD, 1.20] for the placebo group vs. -1.36 (SD, 1.25) for the diclofenac group). The mean difference between groups was -0.28 grade (95% CI, -0.63 to 0.06 grade; P=0.105). Eleven cases of late cardiac tamponade occurred in the placebo group and 9 in the diclofenac group (P=0.64). These differences persisted after adjustment for grade of pericardial effusion at baseline, treatment site, and type of surgery. Therefore, in this trial, the use of diclofenac, 100 mg/d, did not significantly reduce the size of pericardial effusions or the risk for late cardiac tamponade. Moreover, this study confirms that moderate to large pericardial effusion (grade 2, 3, or 4) occurring 7 to 30 days after cardiac surgery is a severe condition because 10.2% of these patients required pericardiocentesis in the 14 days after they enrolled in the study.
Therapy with NSAIDs has been previously considered useful for postoperative pericardial effusions that persist after the first postoperative week. Pericardial effusions and tamponade that occur early after surgery are usually related to surgical bleeding; however, late effusions and tamponade (which are much more frequent) have multiple causal mechanisms, and inflammation seems to play an important role. Postpericardiotomy syndrome may include fever, friction rubs, chest pain, pleuritis, and pericardial effusion. Therefore, use of an NSAID to treat late postoperative pericardial effusions seems logical, and it is common in daily practice (up to 77% of patients in several surveys [2,3,10]). However, patients who have valvular surgery routinely receive oral anticoagulants, and the combination of these agents with an NSAID could provoke gastrointestinal haemorrhage. In addition, use of an NSAID after CABG could promote atherothrombotic complications. Diclofenac was selected for this study because it is widely used and seems not to antagonize the irreversible platelet inhibition induced by aspirin , which is usually prescribed for these patients. However, the main limitation of the study is that it was underpowered to detect small beneficial effects from diclofenac or to evaluate adverse clinical events from the drug, because only 95 patients received the drug.
Although postoperative pericardial effusion is frequent and potentially severe, few randomized, controlled trials have examined treatment for this condition. Recommendation given in the ESC Guidelines to treat postoperative pericardial effusion with NSAIDs was based on the results of the double-blind, placebo-controlled, randomized study by Horneffer et al.  applying a 10-day course of ibuprofen or indomethacin. Of 1019 adult patients undergoing cardiac operations during a 14-month period, a diagnosis of postpericardiotomy syndrome was made in 187, and 149 were enrolled in the study. Diagnosis was based on the presence of at least two of the following: fever, anterior chest pain, and friction rub. Drug efficacy was defined as the resolution of at least two of these criteria within 48 hours of drug initiation. Ibuprofen and indomethacin were 90.2% and 88.7% effective, respectively, and both were significantly more effective than placebo (62.5%, p = 0.003).
The occurrence of side effects, including nausea, vomiting, renal failure, and fluid retention, was low in all groups (13.1% for ibuprofen, 16.1% for indomethacin, and 16.7% for placebo [p = not significant). Length of hospital stay, incidence of ischemic events, and accumulation of significant pericardial effusions were similar in all groups. The results of this study suggested that both ibuprofen and indomethacin provide safe and effective symptomatic treatment for postpericardiotomy syndrome.
Aspirin  and diclofenac  were tested in clinical trials that examined prevention of the postcardiotomy syndrome (not treatment), but these trials included rather limited number of patients. A prospective, randomized, double-blind on primary prevention of postpericardiotomy syndrome was performed by Finkelstein et al  in 163 patients who underwent cardiac surgery in two centres in Israel between. On the 3rd postoperative day, the patients were randomly assigned to receive colchicine (1.5 mg/day) or placebo for 1 month. All were evaluated monthly for the first 3 postoperative months for development of postpericardiotomy syndrome. Of the 111 patients who completed the study, 47 (42.3%) received colchicine and 64 (57.7%) placebo. There was no statistically significant difference between the groups in clinical or surgical characteristics. The postpericardiotomy syndrome was diagnosed in 19 patients (17.1%), 5/47 cases (10.6%) in the colchicine group and 14/64 (21.9%) in the placebo group. However the study was underpowered and the difference showed only a trend toward statistical significance (p < 0.135). Therefore, colchicine is further being tested in an ongoing prevention trial of prevention (COPPS) .
References Part I
1. Maisch B, Seferovic PM, Ristic AD, et al. Task Force on the Diagnosis and Manage-ment of Pericardial Diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases. Executive summary. Eur Heart J 2004;25(7):587-610.
2. Kuvin JT, Harati NA, Pandian NG et al. Postoperative cardiac tamponade in the modern surgical era. Ann Thorac Surg 2002;74(4):1148-53.
3. Tsang TS, Barnes ME, Hayes SN, Freeman WK, Dearani JA, Butler SL, et al. Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979-1998. Chest. 1999;116:322-31.
4. Ashikhmina EA, Schaff HV, Sinak LJ, Li Z, Dearani JA, Suri RM, Park SJ, Orszulak TA, Sundt TM 3rd. Pericardial effusion after cardiac surgery: risk factors, patient profiles, and contemporary management. Ann Thorac Surg 2010;89(1):112-8.
5. Matsuyama K, Matsumoto M, Sugita T et al. Clinical characteristics of patients with constrictive pericarditis after coronary bypass surgery. Jpn Circ J 2001;65(6):480-2.
6. Horneffer PJ, Miller RH, Pearson TA et al. The effective treatment of postpericardiotomy syndrome after cardiac operations. A randomized placebo-controlled trial. J Thorac Cardiovasc Surg 1990;100(2):292-6.
References Part II
7. Ong CK, Lirk P, Tan CH, Seymour RA. An evidence-based update on nonsteroidal anti-inflammatory drugs. Clin Med Res 2007;5:19-34.
8. Antman EM, Bennett JS, Daugherty A, Furberg C, Roberts H, Taubert KA; American Heart Association. Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation. 2007;115:1634-42.
9. Meurin P, Tabet JY, Thabut G, Cristofini P, Farrokhi T, Fischbach M, Pierre B, Driss AB, Renaud N, Iliou MC, Weber H; French Society of Cardiology. Nonsteroidal anti-inflammatory drug treatment for postoperative pericardial effusion: a multicenter randomized, double-blind trial. Ann Intern Med 2010;152(3):137-43.
10. Weitzman LB, Tinker WP, Kronzon I, Cohen ML, Glassman E, Spencer FC. The incidence and natural history of pericardial effusion after cardiac surgery—an echocardiographic study. Circulation 1984;69:506-11.
11. Catella-Lawson F, Reilly MP, Kapoor SC, Cucchiara AJ, DeMarco S, Tournier B, et al. Cyclooxygenase inhibitors and the antiplatelet effects of aspirin. N Engl J Med 2001;345:1809-17.
12. Béland MJ, Paquet M, Gibbons JE, Tchervenkov CI, Dobell AR. Pericardial effusion after cardiac surgery in children and effects of aspirin for prevention. Am J Cardiol 1990;65:1238-41.
13. Niva M, Biancari F, Valkama J, Juvonen J, Satta J, Juvonen T. Effects of diclofenac in the prevention of pericardial effusion after coronary artery bypass surgery. A prospective, randomized study. J Cardiovasc Surg (Torino) 2002;43:449-53.
14. Finkelstein Y, Shemesh J, Mahlab K et al. Colchicine for the prevention of postpericardiotomy syndrome. Herz 2002;27:791-4.
15. Imazio M, Cecchi E, Demichelis B, Chinaglia A, Coda L, Ghisio A, Demarie D, Ierna S, Trinchero R; COPPS Investigators. Rationale and design of the COPPS trial: a randomised, placebo-controlled, multicentre study on the use of colchicine for the primary prevention of postpericardiotomy syndrome. J Cardiovasc Med (Hagerstown). 2007 Dec;8(12):1044-8.
16. Imazio M. Asymptomatic postoperative pericardial effusions: against the routine use of anti-inflammatory drug therapy. Ann Intern Med 2010;152(3):186-7.
European Society of Cardiology
European Heart HouseLes Templiers2035 Route des CollesCS 80179 BIOT
06903Sophia Antipolis, FR
© 2017 European Society of Cardiology. All rights reserved