Transcript ANAFILASSI E SISTEMA CARDIOVASCOLARE Systemic

L’uso dell’Adrenalina nel
paziente Cardiopatico
Giovanni Corrado, FESC
DUOC Cardiologia
Ospedale Valduce – Como
EPINEFRINA NELL’ANAFILASSI
Analisi
rischio/beneficio
ANAFILASSI
• Anaphylaxis is variable and unpredictable. It
may be mild and resolve spontaneously due
to endogenous production of compensatory
mediators or it may be severe and progress
within
minutes
to
respiratory
or
cardiovascular compromise and death
ANAFILASSI
• At the onset of an anaphylactic episode, it is not
possible to predict how severe it will become, how
rapidly it will progress, and whether it will resolve
promptly and completely or not, because the
factors that determine the course of anaphylaxis in
an individual patient are not fully understood.
• Because of these variables, it is important to
administer intramuscular (IM) epinephrine early to
prevent the possible progression to life-threatening
manifestations.
ANAFILASSI
• Epinephrine is the best studied medication in anaphylaxis,
although randomized, placebo-controlled trials of
epinephrine in humans experiencing anaphylaxis have
never been performed for ethical reasons. The evidence
for its use comes from observational studies, randomized,
controlled clinical pharmacology studies in patients not
experiencing anaphylaxis, studies of anaphylaxis in
animal models, and epidemiologic studies, including
fatality studies.
• Several case series have implicated the failure to
administer epinephrine early in the course of treatment
as a consistent finding in anaphylaxis deaths
EPINEFRINA:
EFFETTI
FARMACOLOGICI
ANAFILASSI E SISTEMA
CARDIOVASCOLARE
• Epinephrine increases myocardial contractility, decreases the duration of
systole relative to diastole, and enhances coronary blood flow. Its
transient adverse effects include pallor, tremor, anxiety, and palpitations.
Serious adverse effects (including ventricular arrhythmias and
hypertension) are rare, and are significantly more likely after intravenous
injection than after intramuscular injection. Epinephrine is life-saving in
anaphylaxis; second-line medications (including antihistamines and
glucocorticoids) are not. In CVD patients (especially those with ACS), the
decision to administer epinephrine for anaphylaxis can be difficult, and its
benefits and potential harms need to be carefully considered. Concerns
about potential adverse effects need to be weighed against concerns
about possible death from untreated anaphylaxis, but there is no absolute
contraindication to epinephrine injection in anaphylaxis.
Anaphylaxis and cardiovascular disease: therapeutic dilemmas
P. Lieberman, F. E. R. Simons. Clinical & Experimental Allergy, 2015 (45) 1288–1295.
DEVO USARE L’EPINEFRINA IN UN
PAZIENTE CARDIOPATICO
NOTO O PRESUNTO?
ANAFILASSI E SISTEMA
CARDIOVASCOLARE
• Systemic anaphylaxis is a typical example of
cardiovascular involvement in allergic diseases. Cardiac
and peripheral vascular symptoms dominate the clinical
picture and are often the leading cause of death
• While the skin (urticaria and angioedema) and the
respiratory tract (laryngeal edema and bronchospasm)
are the main organs involved in the early stages of
anaphylaxis, dysfunction of the central and peripheral
cardiovascular systems usually dictates the outcome of
anaphylactic events
ANAFILASSI E SISTEMA
CARDIOVASCOLARE
• Cardiovascular manifestations of anaphylaxis include
hypotension and shock, cardiac arrhythmias, ventricular
dysfunction and cardiac arrest
• A pre-existing coronary artery disease is a negative
prognostic factor of anaphylaxis
• Acute ischaemic events, including angina and
myocardial infarction, are considered currently as part
of the clinical picture of anaphylaxis
SHOCK
• DEFINITION — Shock is defined as a state of cellular and
tissue hypoxia due to reduced oxygen delivery
and/or increased oxygen consumption or inadequate
oxygen utilization. This most commonly occurs when
there is circulatory failure manifested as hypotension
(ie, reduced tissue perfusion). Shock is initially
reversible, but must be recognized and treated
immediately to prevent progression to irreversible
organ dysfunction. "Undifferentiated shock" refers to
the situation where shock is recognized but the cause is
unclear.
SHOCK
CONTRAINDICATIONS
• There are no absolute contraindications to the
administration of epinephrine for anaphylaxis
• Therefore, all patients who have experienced
anaphylaxis should have access to epinephrine for
self-treatment, including pregnant patients at risk
and patients who may be at greater risk for
serious adverse effects, such as older individuals
with cardiovascular disease.
ANAFILASSI E SISTEMA
CARDIOVASCOLARE
• Anaphylaxis is a life-threatening event in which prominent
cardiovascular dysfunction is caused by mediators released
locally from cardiac mast cells
• Both preformed and de novo synthesized mediators concur
to produce deleterious effects on heart function that, when
added to those exerted on peripheral circulation, result in a
rapid and dramatic deterioration of the clinical picture.
• An emerging concept is that anaphylaxis and myocardial
ischaemia are much more connected than thought
previously
ANAFILASSI E SISTEMA
CARDIOVASCOLARE
• Anaphylaxis is more severe and can be more frequently fatal in
patients with coronary artery disease for at least three
mechanisms: (i) mast cells are more abundant and produce more
mediators in hearts with ischaemic cardiomyopathy; (ii)
atherosclerotic lesions make coronary arteries more susceptible
to the effects of mast cell- and basophil-derived mediators; and
(iii) drugs used frequently by patients with ischaemic heart
disease, such as beta-blockers and ACE inhibitors, may aggravate
symptoms or limit efficacy of treatment of anaphylaxis.
• On the other hand, anaphylaxis can be an event precipitating an
acute myocardial ischaemia
ANAFILASSI E SISTEMA
CARDIOVASCOLARE
ANAFILASSI E SISTEMA
CARDIOVASCOLARE
• The coincidental occurrence of chest pain and
allergic reaction, accompanied by the typical
electrocardiographic and laboratory findings
of myocardial ischaemia, is referred to today
as Kounis syndrome and is attributed to an
acute coronary spasm or plaque rupture
induced
by
mediators
of
allergic
inflammation
ANAFILASSI COMPLICATA DA SHOCK-IMA
When you are in
deep sh .... LOOK
STRAIGHT AHEAD,
KEEP YOUR MOUTH
SHUT & SAY
NOTHING
Oppure pensa a come venirne fuori...
GESTIONE IN
EMERGENZA
DELL’ANAFILASSI
NELL’ADULTO
GESTIONE IN
EMERGENZA
DELL’ANAFILASSI
NEL BAMBINO
EPINEFRINA NELL’ANAFILASSI
Scelta decisionale
EPINEFRINA NO
EPINEFRINA SI
EPINEFRINA: EVENTI AVVERSI
• Even when injected properly, epinephrine is often associated
with minor and transient adverse effects such as tremor,
dizziness, palpitations, anxiety, restlessness, and headache
• In contrast, serious adverse effects such as myocardial ischemia
are rare after injection of a 0.3 mg dose in an adult or a 0.15 mg
dose in a child. Such effects occur more commonly
with overdose, especially after intravenous administration.
• Reluctance to administer epinephrine due to fear of adverse
cardiac effects should be countered by the awareness that
myocardial ischemia and dysrhythmias can also occur in
children and adults with anaphylaxis who have not received
epinephrine treatment and in whom no cardiovascular disease
can be found after the episode.
LE NOSTRE CURE
Lev Tolstoj
Guerra e pace
Sebbene i medici lo
curassero, gli
estraessero sangue
e gli dessero da
inghiottire delle
medicine, ciò
nonostante egli
guarì lo stesso
Grazie per l’attenzione