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