Dermatology of the Heart: Tales from the Pericardial Sac

Allan L. Klein, MD, FASE, FRCP (C), FACC, FAHA, and FESC

I have been called a dermatologist of the heart, that is, a doctor that specializes in the skin or pericardial sac. I recently gave grand rounds on new advances in imaging guided therapy of pericarditis at the University of Chicago and Rush University. I demonstrated how advanced imaging, including strain by echo and cardiac magnetic resonance imaging (MRI), can be useful in staging the severity and prognosis of patients with pericarditis. One of the Chicago cardiologists asked me a question about whether exercise would make pericarditis worse. I mentioned that we limit exercise in patients with active pericarditis (target < heart rate of 100 BPM) while they are being tapered on multiple anti-inflammatories. I gave examples of a 20-something-year-old college student that went for a 20-mile bike ride, or the 45-year-old businessman who went power walking for 5 miles and aggravated their symptoms. Latest guidelines limit exercise for 3 months in athletes. I write this page as I read patient tales on social media about pericardial diseases. There are over 1,800 participants on Facebook telling personal stories of what pericarditis has done to their lives. These people are desperate and looking for help, hope, and expertise on how to treat this debilitating condition. This President’s Message provides hope of how we as a Society can help these people and provide awareness about the role of multimodality imaging in the detection and management of pericarditis.

Why is this important to ASE? In 2013, ASE led the medical field by publishing the first guideline about multimodality imaging of the pericardium. This paper laid the groundwork for bringing the pericardial field from the “old days” of assessing pericardial rubs (hard to hear) and evaluating electrocardiograms to the “new days” of using advanced multimodality imaging of the pericardium to guide management. I would like to describe a case of a high school track star who developed acute pericarditis after a viral illness and developed multiple recurrences after doing track meets. He came to our pericardial center of excellence for an evaluation. He had a clinical evaluation with a cardiologist and rheumatologist and advanced imaging. A left ventricular mechanics echo with strain showed a small pericardial effusion ( Figure 1 A) with constrictive physiology with decreased lateral wall to septal wall regional strain ( Figure 1 B) and an MRI showed severe delayed enhancement of the pericardium ( Figure 1 C), indicating severe inflammation and suggesting that he had a severe case of recurrent pericarditis. Based on this clinical scenario, he was treated with a four-drug anti-inflammatory therapy regimen including ibuprofen, colchicine, and prednisone as well as azathioprine over a 2.0-year period and gradually was weaned off all medications.

Apr 15, 2018 | Posted by in CARDIOLOGY | Comments Off on Dermatology of the Heart: Tales from the Pericardial Sac

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