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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