Pericarditi, Miocarditi
e CMP infiammatorie:
cosa c’è di nuovo?
Pericarditi
Massimo Imazio, MD, FESC
Dipartimento di Cardiologia
Ospedale Maria Vittoria, Torino
Pericardite
Medico di
Guardia
Eziologia, Diagnosi
Imazio M, et al. Circulation. 2007;115:2739
Int J Clin Pract 2007; 61: 138
“Everything may
cause pericarditis…”
Imazio M et al. Future Cardiology 2007; 3: 623
Major infectious
agents
1.
2.
3.
4.
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);
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)
Fungal (rare: Histoplasma more likely in
immunocompetent patients,
Aspergillosis, Blastomycosis, Candida
more likely in immunosuppressed host)
Parasitary (very rare: Echinococcus,
Toxoplasma)
SYSTEMATIC BATTERY OF
SEROLOGICAL TESTS
Levy PY et al.Future MIcrobiol 2006; 1(2):229
Acute pericarditis: etiology
Imazio M, et al. Circulation. 2007;115:2739
Imazio M, Trinchero R. Future Cardiology 2007; 3: 623
Triage in acute pericarditis
Clinical and echo evaluation
Is specific etiology highly
suspected or prevalent?
YES
Specific etiology search and
management
NO
Clinical poor prognostic
predictors?
YES
HIGH RISK CASES
NO
LOW RISK CASES
Admission to hospital
Etiology search
Empiric trial with NSAID
Outpatient treatment with NSAID
No Etiology search
Response to NSAID?
NO
MODERATE TO HIGH RISK
YES
LOW RISK PERICARDITIS
Admission to hospital
Etiology search
Outpatient follow-up
No Etiology search
Diagnostic criteria
Imazio M, Trinchero R. J Cardiovasc Med 2007; 8: 404
Etiologic screening
Specific etiology?
Bacterial
pericarditis
(Tbc, purulent)
Neoplastic
pericarditis
Pericarditis related
to systemic disease
Specific etiology
Tuberculous
pericarditis
Search for TBC
(sputum, urine), X-ray,
CT
Pericardiocentesis
Purulent
pericarditis
Neoplastic
pericarditis
Pericardiocentesis
X-ray, mammography,
CT
Pericardiocentesis
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 recidive
Imazio M, Trinchero R Rec Prog Med 2006; 98(5):265-70
Imazio M, et al. Circulation. 2007;115:2739
Prednisone
1mg/Kg/die
Effetti
Recidive
collaterali
gravi
25%
++
0.2-0.5mg/Kg/die <10%
+
Ricoveri
++
+
Nature Cardiovasc Med 2008; in press
Cleve Clin J Med 2007; 74: 385-6
COPE: COlchicine for acute
PEricarditis
40
35
30
25
% 20
15
10
5
0
NNT= 5
36,7
32,3
11,7
8,3
10,7
Corticosteroid therapy:
Recurrences
OR 4.30
95% CI 1.21 to 15.25; p=0.024
0
Symptom18 monthspersistence Drug
recurrence
at 72h
withdrawal rate
No Colchicine
Colchicine
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
Attack
rate
Rec/pt/
month
Brucato A et al. Clin Exp Rheumatol. 2006;24(1): 45-50
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
MOST CASES ARE
BENIGN, TRIAGE FOR
DECISION-MAKING
MD
on duty