急性心包炎

Acute pericarditis,急性心包炎曹泽龙,1,指南的推荐程度和证据水平,类：已证实和（或）一致公认某诊疗措施有益、有用和有效。类：某诊疗措施的有用性和有效性的证据尚有矛盾或存在不同观点。a类：有关证据和（或）观点倾向于有用和有效。b类：有关证据和（或）观点尚不能充分说明有用和有效。 类：已证实和（或）一致公认某诊疗措施无用和无效并在有些病例可能有害，不推荐应用。,证据水平A：资料来源于多项随机临床试验或汇总分析。证据水平B：资料来源于单项随机临床试验或多项非随机试验。证据水平C：专家共识和（或）小型试验结果。,2,病因Aetiology,Viruses： developed countriestuberculosis (TB)： developing countries， often associated with humanimmunodeciency virus (HIV) infection,3,诊断标准,是一种炎症性心包综合征，可伴或不伴心包积液符合以下标准的两项即可诊断:1.胸痛（8590%）：尖痛，坐位与前倾时improve 2. pericardial friction rub心包摩擦音33%：胸骨左缘较明显3.心电图变化up to 60%：广泛导联ST段抬高orPR段压低，心外膜炎症4. pericardial effusion心包积液up to 60%：generally mild,4,常伴有炎症反应指标升高： C-reactive protein(CRP)、 erythrocyte sedimentation rate (ESR)、 white blood cell count；可判断病变活动情况及治疗效果Patients with concomitant myocarditis may present with an elevation （ elve()n）of markers of myocardial injury i.e. creatine kinase (CK), troponinA chest X-ray is generally normal in patients with acute pericarditis since an increased cardiothoracic ratio（心胸比率） only occurs with pericardial effusions exceeding 300 ml,5,Diagnosis,6,Management,7,危险因素,high fever：38Csubacute course (symptoms over several days without a clear-cut acute onset)large pericardial effusion (i.e. diastolic心脏舒张的echo-free space 20 mm)cardiac tamponade（心包填塞）failure to respond within 7 days to NSAIDs次要：Associated with myocarditis (myopericarditis)、immunodepression、trauma、oral anticoagulant抗凝 therapy,8,9,Treatment,Restrict physical activity 普通人（until resolution of symptoms and normalization of CRP、 ECG and echocardiogram ）运动员symptoms have resolved and diagnostic tests(i.e. CRP, ECG and echocardiogram) have been normalized，至少3月Drugs：主要是aspirin or NSAIDsColchicine：kltsin 秋水仙碱：辅助用药，提高治疗效果、预防复发，当上述治疗无效，且排除感染和自身免疫性疾病后可考虑小剂量应用糖皮质激素,10,Treatment,bid.=twice daily; CRP =C-reactive protein=; Tx treatment.a：Tapering should be considered for aspirin and NSAIDs.b：Tx duration is symptoms and CRP guided but generally 12 weeks for uncomplicated cases. Gas