ΟΞΕΙΑ ΚΑΙ ΥΠΟΤΡΟΠΙΑΖΟΥΣΑ ΠΕΡΙΚΑΡΔΙΤΙΔΑ. Βασιλείου Παναγιώτης Α Πανεπιστηµιακή Καρδιολογική Κλινική Ιπποκράτειο ΓΝΑ

Μέγεθος: px

Εμφάνιση ξεκινά από τη σελίδα:

Download "ΟΞΕΙΑ ΚΑΙ ΥΠΟΤΡΟΠΙΑΖΟΥΣΑ ΠΕΡΙΚΑΡΔΙΤΙΔΑ. Βασιλείου Παναγιώτης Α Πανεπιστηµιακή Καρδιολογική Κλινική Ιπποκράτειο ΓΝΑ"

Καλλιγένεια Μήτζου
7 χρόνια πριν
Προβολές:

1 ΟΞΕΙΑ ΚΑΙ ΥΠΟΤΡΟΠΙΑΖΟΥΣΑ ΠΕΡΙΚΑΡΔΙΤΙΔΑ Βασιλείου Παναγιώτης Α Πανεπιστηµιακή Καρδιολογική Κλινική Ιπποκράτειο ΓΝΑ

2 o Acute pericarditis is diagnosed in approximately 0.1% of hospitalized patients and accounts for 5% of emergency department visits for chest pain in the absence of myocardial infarction. o The incidence of acute pericarditis was 27.7 cases per population/year and in 2/3 of cases affect males. Lazaros G, et al. Hellenic J Cardiol 2009;5: Imazio, M, et al. 2008:94:

3 Spectrum of pericardial disorders Acute idiopathic (presumably viral) pericarditis Pericarditis of specific etiology: Recurrent pericarditis Cardiac tamponade Constrictive pericarditis o Uremia o Tuberculosis o Neoplasm o Autoimmune or inflammatory disease o Myocardial infarction o Postcardiotomy syndrome o Trauma o Aortic dissection o Endocrine disorders o Chest wall irradiation o Adverse drug reaction-tooxins Lange R, et al. N Engl J Med 2004;351: Maisch B, et al. Eur Heart J 2004;25:

4 Imazio M, et al. Circulation 2010;121:

6 Diagnostic criteria for acute pericarditis Acute pericarditis is diagnosed when at least 2 of the following criteria are present: o Typical chest pain o Pericardial friction rub o Suggestive ECG changes (typically widespread o ST-segment elevation, PR depression New or worsening pericardial effusion Elevation of CRP is a confirmatory finding and is required for the diagnosis of acute and recurrent pericarditis by some authors. Imazio M, et al. Circulation 2010;121:

7 New criteria Klein A, et al. J Am Soc Echocardiogr 2013;26:

10 Pericarditis Myocarditis Circulation 2010;121:

11 Complications of acute pericarditis Imazio M, et al. Circulation 2011;124:

12 RECURRENT PERICARDITIS DEFINITION OF RECURRENT PERICARDITIS A) a documented first attack of acute pericarditis B) recurrent pain C) and 1 or more of the following signs: fever, pericardial friction rub, electrocardiographic changes, echocardiographic evidence of pericardial effusion, and elevations in the white blood cell count or erythrocyte sedimentation rate or C-reactive protein. Arch Intern Med. 2005; 165:

13 CAUSES OF RECCURENT PERICARDITIS Idiopathic/viral pericarditis Post-myocardial and pericardial injury syndromes -post-pericardiotomy syndrome -post-myocardial infarction syndrome - post traumatic pericarditis Inflammatory-connective tissue diseases Other (rare) Heart 2004;90:

14 Classification Recurrent pericarditis includes two subcategories: i) the intermittent type, in which the interval between the acute episode and recurrence is greater than 6 weeks; and ii) the incessant type, in which the discontinuation (or dose reduction) of anti-inflammatory medication causes a relapse of the symptoms within less than 6 weeks from the acute episode Maisch B, et al Eur Heart J. 2004; 25: Maisch B, Eur Heart J. 2005; 26:

16 ΘΕΡΑΠΕΙΑ ΠΕΡΙΚΑΡΔΙΤΙΔΑΣ

17 o Colchicine which is a standard of care in the treatment of acute pericarditis (either first episode or recurrent disease) doses should be adjusted according to the kidney function. Imazio M, et al. Eur Heart J 2009;30:

18 Suggested tapering rate for prednisone dosage as a function of the original dose given 50mg prednisone=35mg methyl-prednisolone (Medrol) Daily dose of prednisone (mg) Tapering >50 10 mg every 1-2 weeks mg every 1-2 weeks mg every 2-4 weeks < mg every 2-6 weeks Every decrease in prednisone dose should be done only if the patient is asymptomatic and C- reactive protein is normal, particularly for doses 25mg/dL Imazio M, et al. Circulation 2008; 118:

19 Ω

20 Proposed treatment protocol in cases of idiopathic acute pericarditis based on evidence based medicine Lazaros G, Vlachopoulos C, Stefanadis C. Hellenic J Cardiol 2009 ;50:

21 50mg/daily for 1 week 100mg/daily for 1 week Then 2mg/kgr 2mg/kgr at least for 3 months Each dose increase should be preceded by Hct and transaminases measurement.

23 About 5% of IRAP are defined as refractory and they require high long-term doses of corticosteroids to be controlled (IRAP cases that recur after steroid tapering should not be considered refractory). In this situation, immunosuppressive drugs can been used. Lazaros G, Vlachopoulos C, Stefanadis C. Hellenic J Cardiol 2009 ;50:

24 Pericardiectomy Pericardiectomy is reserved only for frequent, strongly symptomatic relapses that are refractory to medication (Class IIa B) Unfortunately, even pericardiectomy occasionally proves ineffective. In one series of patients, only 2 of 9 who underwent pericardiectomy had relief of symptoms. However, the failure to control the symptoms in those cases was probably due to an incomplete pericardiectomy. In cases where the pericardium is completely removed the results appear much better. Eur Heart J. 2004; 25: Ann Thorac Surg. 1991; 52:

25 Prognosis in IRP Despite its negative effect on the patients quality of life, the long-term prognosis is good and patients should be reassured about the benign nature of the disease A recent meta-analysis examined 8 clinical series that included a total of 230 patients with IRP. During a mean follow-up period of 61 months, cardiac tamponade was recorded in 3.5% of cases, while there were no cases of constrictive pericarditis or left ventricular dysfunction. It is emphasized that, the only parameter that has been associated with an increased risk of recurrence after an acute episode of idiopathic pericarditis is the administration of corticosteroids whereas colchicine is the only agent with a demonstrated protective effects against recurrences. Circulation. 2007; 115: Am J Cardiol. 2007; 100:

26 Asymptomatic pericardial effusion with normal CRP: therapy is unknown But probably not necessary

27 Conclusions o Τα περικαρδιακά νοσήµατα αποτελούν συχνή νοσολογική οντότητα που αν και επηρεάζει την ποιότητα ζωής των ασθενών, έχει πολύ καλή πρόγνωση

28 Conclusions o Τα περικαρδιακά νοσήµατα αποτελούν συχνή νοσολογική οντότητα που αν και επηρεάζει την ποιότητα ζωής των ασθενών, έχει πολύ καλή πρόγνωση. Η πρώιµη χορήγηση κορτικοστεροειδών έχει συσχετιστεί µε αυξηµένο κίνδυνο εµφάνισης υποτροπών, ενώ αντίθετα η κολχικίνη µειώνει τον κίνδυνο εµφάνισης υποτροπών.

29 Conclusions o o Τα περικαρδιακά νοσήµατα αποτελούν συχνή νοσολογική οντότητα που αν και επηρεάζει την ποιότητα ζωής των ασθενών έχει πολύ καλή πρόγνωση. Η πρώιµη χορήγηση κορτικοστεροειδών έχει συσχετιστεί µε αυξηµένο κίνδυνο εµφάνισης υποτροπών, ενώ αντίθετα η κολχικίνη µειώνει τον κίνδυνο εµφάνισης υποτροπών Η χορήγηση κορτικοστεροειδών γίνεται κάθε προσπάθεια να αποφευχθεί και επιφυλάσσεται σε ασθενείς µε δυσανεξία στα NSAIDS, σε βαρέως πάσχοντες ή σε περίπτωση µη ανταπόκρισης στην παραπάνω αγωγή καθώς και σε γνωστή αλλεργία σε κάποιο από τα NSAIDS.

30 ΕΥΧΑΡΙΣΤΩ ΓΙΑ ΤΗΝ ΠΡΟΣΟΧΗ ΣΑΣ

31 Hazard ratio, 2.36, P=0.004 Conclusions Hs-CRP is elevated at the initial presentation in 3 of 4 cases of acute pericarditis, identifies patients at higher risk of recurrence, and could be used to monitor disease activity and select appropriate therapy length.

32 100 patients with recurrent pericarditis [idiopathic, autoimmune (including post-pericardiectomy syndrome) and recurrent pericarditis in the setting of connective tissue diseases]. About half of the patients (49) were given low doses of prednisone ( mg/kg/day), while the others received a high dose (1 mg/kg/ day). 32% 64.7% It was found, paradoxically, that the recurrence rate was about double in the patients taking the high dosage (64.7% vs. 32.6%, p=0.002), while the incidence of adverse effects was also higher in that group of patients (23.5% vs. 2%, p=0.002)

34 Management of pericarditis NSAIDS Are considered the cornerstone of treatment Protocols for the administration of NSAIDs do not actually differ from those used in acute idiopathic pericarditis Most usually, aspirin is given in a daily dose of 2-4gr administered every 4-6 hours, ibuprofen gr daily every 6-8 hours, and indomethacin mg daily every 6-8 hours as well, with a similar efficacy as regards pain relief and suppression of inflammation (85-90% success) It should be noted that NSAIDs have no effect in preventing further recurrences, or other complications such as cardiac tamponade and constrictive pericarditis PPI should be always coadministered. Eur Heart J. 2004; 25: N Engl J Med. 2004; 351: Circulation. 2006; 113: Arch Intern Med. 2005; 165:

35 Circulation 2006;113: Circulation 2010;121:

36 1. ΠΗΛΙΚΟ Α/ Β=2/5=0,4 (>0,25) Α Β Απαγωγή V 6 2. ΠΗΛΙΚΟ Α/ Β=1,5/9=0,16 (<0,25) Απόσταση Α: Τέλος PQ διαστήµατος έως την αρχή του ST διαστήµατος Απόσταση Β: Τέλος PQ διαστήµατος έως την µέγιστη ανάσπαση του ST διαστήµατος

37 ΗΛΕΚΤΡΟΚΑΡΔΙΟΓΡΑΦΗΜΑ ACUTE PERICARDITIS MYOCARDIAL INFARCTION

41 Cardiology 2011;119(3):

42 ΥΠΟΚΕΙΜΕΝΗ ΔΙΑΓΝΩΣΗ ΣΕ ΕΠΙΠΩΜΑΤΙΣΜΟ ΜΕ ΑΙΜΑΤΗΡΗ ΣΥΛΛΟΓΗ ΠΕΡΙΚΑΡΔΙΑΚΟΥ ΥΓΡΟΥ

Σχετικά έγγραφα

ΟΞΕΙΑ ΠΕΡΙΚΑΡΔΙΤΙΣ. 3o ΕΠΙΜΟΡΦΩΤΙΚΟ ΣΕΜΙΝΑΡΙΟ ΕΙΔΙΚΕΥΟΜΕΝΩΝ 2013. Βασιλική Ματζαράκη ΜD ΓΝΑ Γ.ΓΕΝΝΗΜΑΤΑΣ 30 ΝΟΕΜΒΡΙΟΥ 2013

ΟΞΕΙΑ ΠΕΡΙΚΑΡΔΙΤΙΣ. 3o ΕΠΙΜΟΡΦΩΤΙΚΟ ΣΕΜΙΝΑΡΙΟ ΕΙΔΙΚΕΥΟΜΕΝΩΝ 2013. Βασιλική Ματζαράκη ΜD ΓΝΑ Γ.ΓΕΝΝΗΜΑΤΑΣ 30 ΝΟΕΜΒΡΙΟΥ 2013 ΟΞΕΙΑ ΠΕΡΙΚΑΡΔΙΤΙΣ 3o ΕΠΙΜΟΡΦΩΤΙΚΟ ΣΕΜΙΝΑΡΙΟ ΕΙΔΙΚΕΥΟΜΕΝΩΝ 2013 Βασιλική Ματζαράκη ΜD ΓΝΑ Γ.ΓΕΝΝΗΜΑΤΑΣ 30 ΝΟΕΜΒΡΙΟΥ 2013 ΑΝΑΤΟΜΙΑ ΚΑΙ ΦΥΣΙΟΛΟΓΙΑ ΠΕΡΙΚΑΡΔΙΟΥ Το περικάρδιο αποτελείται από δύο χιτώνες: 1.