Pericarditi, Miocarditi e CMP infiammatorie: cosa cè di nuovo? Pericarditi Massimo Imazio, MD, FESC...
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Transcript of Pericarditi, Miocarditi e CMP infiammatorie: cosa cè di nuovo? Pericarditi Massimo Imazio, MD, FESC...
Pericarditi, Miocarditi Pericarditi, Miocarditi e CMP infiammatorie: e CMP infiammatorie:
cosa c’è di nuovo? cosa c’è di nuovo? Pericarditi Pericarditi
Massimo Imazio, MD, FESCMassimo Imazio, MD, FESCDipartimento di CardiologiaDipartimento di Cardiologia
Ospedale Maria Vittoria, TorinoOspedale Maria Vittoria, Torino
Medico di Guardia
Pericardite
Eziologia, Diagnosi
Imazio M, et al. Circulation. 2007;115:2739
“Everything may
cause pericarditis…”
Int J Clin Pract 2007; 61: 138
Imazio M et al. Future Cardiology 2007; 3: 623
Levy PY et al.Future MIcrobiol 2006; 1(2):229Levy PY et al.Future MIcrobiol 2006; 1(2):229
Major infectious agents
1. Viral (most common: Echovirus and Coxsackievirus (usual), Influenza, EBV, CMV, Adenovirus, Varicella, Rubella, Mumps, HBV, HCV, HIV, Parvovirus B19 and Human Herpes Virus 6 (increasing reports);
2. Bacterial (most common: tuberculous (4-5%), Coxiella burnetii (5-7%?), other bacterial rare may include Pneumo-, Meningo-, Gonococcosis, Haemophilus, Staphylococci, Chlamydia, Mycoplasma, Legionella, Leptospira, Listeria)
3. Fungal (rare: Histoplasma more likely in immunocompetent patients, Aspergillosis, Blastomycosis, Candida more likely in immunosuppressed host)
4. Parasitary (very rare: Echinococcus, Toxoplasma)
SYSTEMATIC BATTERY OF SYSTEMATIC BATTERY OF SEROLOGICAL TESTSSEROLOGICAL TESTS
Acute pericarditis: etiologyAcute pericarditis: etiology
Imazio M, et al. Circulation. 2007;115:2739Imazio M, Trinchero R. Future Cardiology 2007; 3: 623
Triage in acute pericarditisTriage in acute pericarditis
Clinical and echo evaluationIs specific etiology highly suspected or prevalent?
YESSpecific etiology search and
management
NOClinical poor prognostic
predictors?
YESHIGH RISK CASES
NOLOW RISK CASES
Outpatient treatment with NSAIDNo Etiology search
Response to NSAID?
NOMODERATE TO HIGH RISK
YESLOW RISK PERICARDITIS
Outpatient follow-upNo Etiology search
Admission to hospitalEtiology search
Admission to hospitalEtiology search
Empiric trial with NSAID
Diagnostic criteria
Imazio M, Trinchero R. J Cardiovasc Med 2007; 8: 404
Etiologic screening
Specific etiology?
Bacterial pericarditis
(Tbc, purulent)
Neoplasticpericarditis
Pericarditis related to systemic disease
Specific etiology
Tuberculous pericarditis
Purulentpericarditis
Neoplastic pericarditis
Search for TBC (sputum, urine), X-ray,
CTPericardiocentesis
PericardiocentesisX-ray, mammography,
CTPericardiocentesis
Am J Cardiol 2007; 99: 1294-7
Pathogenesis of
recurrences
Imazio M, Trinchero R. Future Cardiology 2007; 3: 623
Etiology of recurrent pericarditis
Terapia
ASA o FANS
Aspirina 2-4g/die
Ibuprofene 1200-1800mg/die
Indometacina 75-150mg/die
Nimesulide 200mg/die
Imazio M et al. J Cardiovasc Med 2007; 8: 748
Corticosteroidi come FR per le recidiveCorticosteroidi come FR per le recidive
Imazio M, et al. Circulation. 2007;115:2739
Imazio M, Trinchero R Rec Prog Med 2006; 98(5):265-70
Nature Cardiovasc Med 2008; in press
Prednisone Effetti collaterali gravi
Recidive Ricoveri
1mg/Kg/die 25% ++ ++
0.2-0.5mg/Kg/die <10% + +
Cleve Clin J Med 2007; 74: 385-6
COPE: COlchicine for acute PEricarditis
NNT= 536,7
11,7
0
8,3
32,3
10,7
0
5
10
15
20
25
30
35
40
%
Symptom-persistence
at 72h
18 months-recurrence
rate
No Colchicine Colchicine
Corticosteroid therapy:RecurrencesOR 4.30 95% CI 1.21 to 15.25; p=0.024
Drug withdrawal
Imazio M et al. Circulation 2005; 112(13):2012-6.
Colchicina e recidive
Imazio M, Trinchero R Rec Prog Med 2006; 98(5):265-70
Colchicina e storia naturale della pericardite recidivante
Brucato A et al. Clin Exp Rheumatol. 2006;24(1): 45-50
Attack rate
Rec/pt/month
Colchicine: How does it work?
Imazio M, Trinchero R. Future Cardiology 2007; 3: 623
Imazio M, Trinchero R. Future Cardiology 2007; 3: 623
Colchicina e pericardite:Trials in corso
Imazio M et al. JCM 2007; Dic; 8(12):1044-8
Imazio M et al. JCM 2007; Oct;8(10):830-4
Imazio M et al. JCM 2007; Aug;8(8):613-7.
Clin Sci 2007; 113(11):443-8
JCM 2007; 8: 748-53
Prognosi
Am J Cardiol 2007; 100:1026
MD
on duty
MOST CASES ARE BENIGN, TRIAGE FOR DECISION-MAKING