Επείγοντα καρδιολογικά προβλήματα- Διαγνωστικές και θεραπευτικές προκλήσεις Οξεία περικαρδίτιδα

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1 Επείγοντα καρδιολογικά προβλήματα- Διαγνωστικές και θεραπευτικές προκλήσεις Οξεία περικαρδίτιδα Γ. Λάζαρος Επιμελητής Α Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Γ.Ν.Α

2 The nrmal pericardium is a fibrelastic sac surrunding the heart that cntains a small amunt f pericardial fluid (10 50 ml), which is prduced by the visceral (internal) layer f the pericardium. Little W et al. Circulatin 2006;113:

3 Acute pericarditis is diagnsed in apprximately 0.1% f hspitalized patients and accunts fr 5% f emergency department visits fr chest pain in the absence f mycardial infarctin. The incidence f acute pericarditis was 27.7 cases per 100,000 ppulatin/year and in 2/3 f cases affect males. Kyt V et al. Circulatin 2014;130: Imazi M et al. Circulatin 2010;121:

4 Spectrum f pericardial disrders Acute idipathic (presumably viral) pericarditis Pericarditis f specific etilgy: Recurrent pericarditis Cardiac tampnade Cnstrictive pericarditis Uremia Tuberculsis Neplasm Autimmune r inflammatry disease Mycardial infarctin Pstcarditmy syndrme Trauma Artic dissectin Endcrine disrders Chest wall irradiatin Adverse drug reactin-txins Lange R, et al. N Engl J Med 2004;351: Maisch B, et al. Eur Heart J 2004;25:

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6 Spectrum f pericardial disrders Acute idipathic (presumably viral) pericarditis Pericarditis f specific etilgy: Recurrent pericarditis Cardiac tampnade Cnstrictive pericarditis Uremia Tuberculsis Neplasm Autimmune r inflammatry disease Mycardial infarctin Pstcarditmy syndrme Trauma Artic dissectin Endcrine disrders Chest wall irradiatin Adverse drug reactin-txins Lange R, et al. N Engl J Med 2004;351: Maisch B, et al. Eur Heart J 2004;25:

7 Cmplicatins f acute pericarditis Imazi M, et al. Circulatin 2011;124:

8 Imazi M, et al. Circulatin 2010;121:

9 Diagnstic criteria Klein A, et al. J Am Sc Echcardigr 2013;26:

10 Pericardial frictin rub

11 ECG in acute pericarditis

12 DD acute pericarditis vs. early replarizatin Ginztn L, et al. Circulatin 1982;65:

13 Differential diagnsis amng thers Acute mycardial infarctin Acute pulmnary emblism Acute respiratry tract infectins Acute artic syndrmes Gastresphageal reflux Musculskeletal pain

14 Diagnstic wrk up Lazars G, et al Cardilgy 2011;119:

15 Management f acute pericarditis Physical activity in patients with IRP must be limited until the cmplete remissin f fever and chest pain. Lazars G et al. HJC 2009 ;50: Eur Heart J. 2004; 25:

16 Clinical pr prgnstic predictrs fr pericarditis with need fr hspitalizatin Baseline features assciated with a specific (secndary cause) Fever>38 C Subacute nset Large pericardial effusin Cardiac tampnade Lack f respnse t aspirin r NSAIDs after at least 1 week f therapy Baseline features assciated with cmplicated in-hspital curse Mypericarditis Immundepressin Trauma Oral anticagulant therapy Little W et al. Circulatin 2006;113: Lange RA et al. NEJM 2004;351: Imazi M et al. Circulatin 2010;121:

17 NSAIDs Are cnsidered the crnerstne f treatment and suppress inflammatin in 85-90% f cases. It shuld be nted that NSAIDs have n effect in preventing further recurrences, r ther cmplicatins such as cardiac tampnade and cnstrictive pericarditis A PPI shuld be always c-administered. Eur Heart J. 2004;25: N Engl J Med. 2004; Circulatin. 2006;113: Arch Intern Med 2005;165:

18 Imazi M. Curr Opin Cardil 2012;27:

19 Treatment length with NSAIDs The best length f treatment with NSAIDS is nt clearly established, but a reasnable time is that sufficient t induce symptms regressin and nrmalizatin f inflammatry markers (CRP), generally 1 2 weeks. Expert Rev Cardivasc Ther 2012;10;

20 Hazard rati, 2.36, P=0.004 Cnclusins: hs-crp is elevated at week1 f acute idipathic pericarditis, identifies patients at higher risk f recurrence, and culd be used t mnitr disease activity and select apprpriate therapy length.

21 Clchicine (n tp d NSAIDs!) It inhibits mitses in the cell nucleus. The drug is als able t cncentrate in leuccytes, where it exerts marked effects, altering adhesin, mbility, and cytkine prductin. Imazi M. Eur Heart J 2009;30: Maisch B, et al. Eur Heart J 2004;25:

22 Clchicine in the first episde f acute pericarditis The primary utcme ccurred in 20 patients (16.7%) in the clchicine grup and 45 patients (37.5%) in the placeb grup (relative risk reductin in the clchicine grup, 0.56, cnfidence interval, 0.30 t 0.72; number needed t treat, 4; p<0.001). N Engl J Med 2013;369:

23 Safety issues The mst usual adverse effect was diarrhea, which required interruptin f the medicatin in 7% f cases. Anther cmmn adverse effect f clchicine is a mderate increase in transaminases (7% f cases) A lading dse f 1 mg fllwed by a maintenance dse f 0.5 mg is reserved fr patients with bdy weight >70 kg and thse aged <70 years Imazi M. et al. Arch Intern Med. 2005;165: Imazi M, et al.eur Heart J 2009;30:

24 Crticsterids Accrding t the current guidelines in patients with a pr general cnditin, in cases f NSAIDs failure, and in frequent, hard-t-cntrl recurrences (Class IIa C) The guidelines recmmend a dse f mg/kgr prednisne fr at least 1 mnth, tapered ver a three-mnth perid. Eur Heart J. 2004;25: Am J Cardil : J Cardivasc Med (Hagerstwn) 200;8: Circulatin 2008;118: Circulatin 2006;113:

25 100 patients with recurrent pericarditis Half f the patients were given lw dses f prednisne ( mg/kg/day), while the thers received a high dse (1 mg/kg/day). 32% 64.7% It was als fund a lwer incidence f adverse effects in the lw dse regimen (23.5% vs. 2%, p=0.002). Imazi M, et al. Circulatin 2008;118:

26 Cardiac tampnade r suspected bacterial r neplastic etilgy? Yes Pericardicentesis and etilgy search N Elevated inflammatry markers? Therapeutic apprach in cases f acute pericarditis with pericardial effusin Yes Treat as pericarditis N Assciated disease (knwn r unveiled)? Yes Prbably related. Treat the disease N Large effusin (>20mm)? Eur Heart J 2013;34: Circulatin 2010;121; Curr Opin Cardil 2012;27: Yes Cnsider pericardicentesis and drainage if chrnic (>3 mnths) N Fllw-up

27 Prgnsis The in-hspital mrtality f acute pericarditis is estimated at 1.1% Prgnsis is excellent in idipathic pericarditis and depends n the underlying cnditin in the secndary frms. Cmplicatins include recurrent pericarditis, cardiac tampnade and permanent cnstrictive pericarditis Kytö V, et al. Circulatin 2014;130:

28 Idipathic recurrent pericarditis = idipathic recurrent pericarditis frever! In a series f 61 patients wh were referred t a tertiary hspital fr resistant idipathic recurrent pericarditis were fllwed fr an average f 8.3 years: In (70.5%), pericarditis remained idipathic, whereas a new diagnsis f systemic inflammatry disease (namely and rheumatid arthritis and Sjgren s syndrme) was subsequently made in the rest. Key message Idipathic recurrent pericarditis is nt necessarily a lifelng diagnsis! Brucat A et al. Am J Cardil 2006;98:

29 Majr challenge in patients with a first episde f acute pericarditis Identificatin f patients prne t recurrences! Assciated with recurrences Crticsterids Secndary frms f pericarditis Persistently elevated CRP despite adequate treatment Prtect against recurrences Clchicine

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