Περικαρδίτιδα στην καρδιακή ανεπάρκεια

Transcription

1 ΣΕΜΙΝΑΡΙΑ ΟΜΑΔΩΝ ΕΡΓΑΣΙΑΣ, ΙΩΑΝΝΙΝΑ 2015 Περικαρδίτιδα στην καρδιακή ανεπάρκεια Γεώργιος Λάζαρος Α Πανεπιστηµιακή Καρδιολογική Κλινική Ιπποκράτειο Γ.Ν. Αθηνών

2 I declare that I have no conflict of interest

3 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 Lazaros G, et al. Hellenic J Cardiol 2009;5:

4 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:

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

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

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10 Upcoming ESC guidelines on pericardial diseases 2015

11 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 ST-segment elevation, PR depression o New or worsening pericardial effusion Elevation of CRP is a confirmatory finding and is required for the diagnosis of acute and recurrent Imazio M, et al. Circulation 2010;121:

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

13 Distinct features of acute pericarditis in patients with chronic heart failure o Actually the are no significant differences with respect to etiology, diagnostic work-up and outcome of acute pericarditis in patients with chronic heart failure. o However, in the above patients there is concern about the fluid retention due to NSAIDs administration which may decompensate stable patients. o Moreover, the eventual increase of blood pressure due to

14 o Moreover, given the high prevalence of chronic kidney disease in chronic heart failure patients (~40%) NSAIDs should be administered at the lower effective doses and for the shorter possible period in patients with creatinine clearance <50ml/min whereas there are contraindicated in patients with clearance below (aspirin is allowed for clearance>10ml/min). o In the above patients corticosteroids may constitute an

15 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:

16 Isolated pericardial effusion in heart failure o The normal pericardial fluid is an ultrafiltrate of plasma and characteristically has a low protein concentration similar electrolyte composition and low specific gravity. o It is produced by the serosal layer of the pericardium and it

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18 DD between transudate and exudate CT attenuation values 35 to 50 HU, measuring 8 mm in Hounsfield units 0-20 transudate exudate >60 hemorrhage Negative chylopericardium Verhaert D, et al. Circ Cardiovasc Imaging 2010;3:

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20 o The prevalence of pericardial and pleural effusions has been reported at 12% - 20% and 87%, respectively in CHF. o Pericardial effusion forms only with elevation of the right-sided filling pressure Natanzon A, et al. Am J Med Sci 2009;338: Kataoka H. Am Heart J 2000;139: Maisch B. Curr Opin Cardiol 1994;9: Kessler KM, et al. Chest 1980;78:

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22 o A total of 897 patients (824 patients in the control vs. 73 patients in the PE group) were included. o End points: all-cause mortality as the primary and cardiovascular death or need for heart transplantation as secondary outcomes. o The median follow-up period was 4.4 months (IQR: 1.8 Frohlich G, et al. Eur Heart J 2013:34:

23 * Frohlich G, et al. Eur Heart J 2013:34:

24 Frohlich G, et al. Eur Heart J 2013:34:

25 Frohlich G, et al. EHJ 2013:34:

26 Parameters of the right ventricular function and dimension. RVareaD (cm 2 ) Fractional area change % TAM (mm) Frohlich G, et al. Eur Heart J 2013:34:

27 Frohlich G, et al. Eur Heart J 2013:34:

28 Things are not always so simple

29 o o o o o 51 year-old-patient 1 month ago acute anterior myocardial infarction treated with primary PCI with stent >6h after symptoms onset During hospitalization pneumonia treated with antibiotics Discharged 2 weeks later with EF~30, without pericardial-pleural effusion, normal CRP, BNP~2000pg/ml Admission 1 month after PCI complaining of dyspnea, without chest pain

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33 HEART FAILURE (HYRDOPERICARDIUM) ACUTE (INFECTIVE) PERICARDITIS DRESSLER SYNDROME

34 1. Hydropericardium?: Pros: -EF, BNP left ventricular filling pressures Cons: - Late appearance of effusion (in particular when BNP values were decreasing) in the absence of an evident trigger such as infection, recurrent ischemia, arrhythmia, etc.

35 2. Dressler syndrome?: Pros: -Absence of pericardial effusion which first appeared 3 weeks after MI - CRP in the absence of evidence of infection Cons: -Absence of chest pain compatible with pericarditis, fever and leukocytosis -Dressler syndrome is rare in the era of primary angioplasty

36 Idiopathic (viral) pericarditis?: Pros: -3 weeks earlier respiratory infection. -Elevation and then decrease of CRP values -Pleuropericardial effusion (in 30% of pericarditis coexist pleural effusion) 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 ST-segment elevation, PR depression o New or worsening pericardial effusion

37 Answer?

38 o o o Increase in diuretic doses administration along with optimization of heart failure treatment. Increase of aspirin dose (from 100mg to 2,2mg daily) and colchicine administration (1mg/daily). In the following days improvement of symptoms with normalization

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

40 Pericardial LGE indicates ongoing pericardial Circulation 2011, 124:

41 Conclusions o o Acute pericarditis in heart failure patients does not have any specific features as compared with patients without. However, treatment with NSAIDs is a matter of concern given the high prevalent of chronic kidney disease in these patients and the fear for heart failure decompensation (due to blood pressure elevation and fluid retention caused by the latter medications). Isolated pericardial effusions in heart failure patients are associated with right ventricular failure.

42 Conclusions o o Acute pericarditis in heart failure patients does not have any specific features as compared with patients without. However, treatment with NSAIDs is a matter of concern given the high prevalent of chronic kidney disease in these patients and the fear for heart failure decompensation (due to blood pressure elevation and fluid retention caused by the latter medications). Isolated pericardial effusions in heart failure patients are associated with right ventricular failure.

43 Conclusions o o Acute pericarditis in heart failure patients does not have any specific features as compared with patients without. However, treatment with NSAIDs is a matter of concern given the high prevalent of chronic kidney disease in these patients and the fear for heart failure decompensation (due to blood pressure elevation and fluid retention caused by the latter medications). Isolated pericardial effusions in heart failure patients are associated with right ventricular failure.

44 Thank you for your attention

45 Back-up slides