Cardiovascular Journal of Africa: Vol 27 No 6 (November/December 2016)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 6, November/December 2016

354

AFRICA

This pilot study could not demonstrate any benefit derived

from the addition of colchicine to the routine management of

HIV-positive patients with TB pericarditis. The power of this

pilot trial was insufficient to detect small differences in outcome;

however, it appears that colchicine use has no correlation with

the prevention or formation of post-TB CP. This pilot trial could

not assess the beneficial effects of colchicine in the HIV-negative

patient with TB pericarditis.

After considering the findings of this pilot research, the costs

of the drug, the polypharmacy these patients are exposed to,

drug–drug interactions and side effects (albeit mild), this study

would advise against the use of colchicine in the management of

HIV-positive patients with TB pericarditis.

The implementation of a pericardiocentesis until dryness

(with or without extended drainage) was up to this point

never studied in a controlled or comparative manner. Research

conducted by Reuter

et al

in 2007 found the first evidence to

suggest the benefit of a pericardiocentesis until dryness with

extended drainage. In their research, 162 patients with TB

pericarditis underwent pericardiocentesis, and over a follow-

up period of six years, only two patients (1.23%) developed

fibrous pericardial constriction. The research concluded that

echocardiographic-guided pericardiocentesis with extended

drainage is a safe and effective management option, and when

combined with short-course anti-tuberculous therapy, it almost

completely prevents the development of CP.

Afewleadingcentresareemployingaroutine‘pericardiocentesis

until dryness’ approach based on this literature, whereas most do

not. The interesting observation made in our pilot study was that

the findings made by Reuters

et al.

in 2007 were reproducible on

a much smaller scale. Pericardial constriction, although having

a low incidence, was almost exclusively seen in the group that

did not undergo pericardiocentesis (observational – disregard

original group allocation). As suggested by some expert opinion

and as supported by the data published by Reuters

et al.

and observational findings of our pilot trial, the practice of

routine pericardiocentesis until dryness in the absence of contra-

indications appears to be the preferred management option

and this might well be the long-awaited ‘eureka moment’, in an

attempt to halt the development of pericardial constriction.

Limitations of the study

The diagnosis of pericardial constriction was made with

echocardiography, whereas the gold standard for diagnosing

CP is invasive haemodynamic studies. Work done by Oh

et al

and Boonyaratevej

et al

demonstrated that one of the most

characteristic findings of CP, a respiratory variation in early

transmittal inflow velocity, is neither perfect in its sensitivity

nor specificity for the diagnosis. In patients with markedly

elevated left atrial pressures, the respiratory variation in the

inflow velocities may be less than 25%. Furthermore, in patients

with chronic obstructive pulmonary disease and severe right

ventricular dysfunction, the variation may be elevated in the

absence of CP. This research emphasises the importance of using

a variety of recognised echocardiographic diagnostic tools to

confirm a non-invasive diagnosis of CP.

The duration of follow up was only four months. Some

comparative research had follow-up periods of up to six years.

Most patients who develop CP, do so in a period of three to four

months. There may however be patients who will only develop

constriction after four months. Research to address this aspect

may be valuable.

Corticosteroids were used as part of the standard therapy in

all patients. However, subsequent to the initiation of the research,

the IMPI trial brought to light their findings that corticosteroids

should not be used in TB pericarditis in HIV-infected patients.

The South African National TB guidelines published in 2014 still

advised the use of corticosteroids in all patients and the findings

of the IMPI trial had not yet been incorporated into current

South African National Tuberculosis Management Guidelines.

Conclusion

Based on current research, the use of colchicine in addition

to standard antituberculous therapy cannot be advised in the

context of TB pericarditis in the HIV-positive population. The

jury is still out on which adjuvant strategies may prove to be

beneficial in the prevention of CP, especially in the HIV-co-

infected subgroup. Based on observations from this research and

some other studies, routine pericardiocentesis until dryness with

extended drainage may prove to be the long-awaited solution to

the common dilemma of post-TB CP.

Our special thanks go to Ms Kassandra Barnard, Dr Danie Steenkamp and

Dr Pieter van Der Bijl for technical assistance and quality control with the

echocardiographic assessment of study participants. Our sincere gratitude

goes to Mr Shaun Zeelie for supplying and monitoring the treatment of the

participants.

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