288 Pericardial Disease

Question 1

Amount of fluid between the two layers of pericardium?

Answer 1

15–50 mL

Question 2

Characterize the pain in acute pericarditis.

Answer 2

severe, retrosternal, and left precordial and referred to the neck, arms, or left shoulder, pleuritic, pain may be relieved by sitting up and leaning forward and is intensified by lying supine

Question 3

When is pain absent?

Answer 3

Pain is often absent in slowly developing tuberculous, postirradiation, and neoplastic, uremic, and constrictive pericarditis.

Question 4

How do you differente an AMI from an acute pericarditis serum if there is elevation of biomarkers of myocardial damage?

Answer 4

These elevations, if they occur, are quite modest given the extensive electrocardiographic STsegment elevation in pericarditis.

Question 5

ECG 4 stages in acute pericarditis.

Answer 5

In stage 1, there is widespread elevation of the ST segments, often with upward concavity, involving two or three standard limb leads and V to V , with reciprocal depressions only in aVR and sometimes V . Also, there is depression of the PR segment below the TP segment, reflecting atrial involvement. Usually there are no significant changes in QRS complexes. After several days, the ST segments return to normal (stage 2), and only then, or even later, do the T waves become inverted (stage 3). Weeks or months after the onset of acute pericarditis, the ECG returns to normal (stage 4).

Question 6

Physical examination with pericardial effusion?

Answer 6

heart sounds may be fainter; the friction rub and the apex impulse may disappear; the base of the left lung may be compressed by pericardial fluid, producing Ewart’s sign

Question 7

ECG with with pericardial effusion?

Answer 7

ECG of pericarditis and electrical alternans.

Question 8

MRI and CT are superior to ultrasound in detecting which lesions?

Answer 8

loculated pericardial effusions, pericardial thickening, and the identification of pericardial masses.

Question 9

therapy for acute idiopathic pericarditis

Answer 9

There is no specific therapy for acute idiopathic pericarditis, but bed rest and antiinflammatory
treatment with aspirin (2–4 g/d), with gastric protection (e.g., omeprazole 20 mg/d), may be given. If this is ineffective, one of the nonsteroidal antiinflammatory
drugs (NSAIDs), such as ibuprofen (400–600 mg tid) or indomethacin (25–50 mg tid), should be tried.

Question 10

What are the most common causes of tamponade?

Answer 10

The most common causes of tamponade are idiopathic pericarditis and pericarditis secondary to neoplastic disease.

Question 11

Describe Beck’s triad.

Answer 11

Beck’s triad - are hypotension, soft or absent heart sounds, and jugular venous distention with a prominent x descent but an absent y descent.

Question 12

What is the quantity of fluid necessary to produce cardiac tamponade?

Answer 12

The quantity of fluid necessary to produce cardiac tamponade may be as small as 200 mL when the fluid develops rapidly to as much as more than 2000 mL in slowly developing effusions.

Question 13

ECG changes in cardiac tamponade.

Answer 13

There may be reduction in amplitude of the QRS complexes, and electrical alternans of the P, QRS, or T waves should raise the suspicion of cardiac tamponade

Question 14

Diseases in which there is pulso paradoxus?

Answer 14

Cardiac tamponade. Paradoxical pulse also occurs in
approximately one third of patients with constrictive pericarditis (see below), and in some cases of hypovolemic shock, acute and chronic obstructive airway disease, and pulmonary embolus.

Question 15

What is low pressure tamponade?

Answer 15

mild tamponade in which the intrapericardial pressure is increased to +5 to +10 mmHg; in some instances, hypovolemia coexists. As a consequence, the central venous pressure is normal or only slightly elevated, whereas arterial pressure is unaffected and there is no
paradoxical pulse. These patients are asymptomatic or complain of mild weakness and dyspnea.

Question 16

What can cause bloody fluid in tamponade?

Answer 16

most commonly due to neoplasm, renal failure, or dialysis in the United States and tuberculosis in developing nations but may also be found in the effusion of acute rheumatic fever, after cardiac injury, and after myocardial infarction.

Question 17

acute pericarditis can be caused by which virus?

Answer 17

coxsackievirus A or B or the virus of influenza, echovirus, mumps, herpes simplex, chickenpox, adenovirus, or cytomegalovirus. Pericardial effusion is a common cardiac manifestation of HIV

Question 18

In HIV, acute pericarditis is usually secondary to which diseases?

Answer 18

Pericardial effusion is a common cardiac manifestation of HIV; it is usually secondary to infection (often mycobacterial) or neoplasm

Question 19

What is the most frequent complication of pericarditis?

Answer 19

most frequent complication is recurrent (relapsing) pericarditis, which occurs in about one-fourth of patients with acute idiopathic pericarditis.

Question 20

What is the main symptom in Postcardiac Injury Syndrome? How long after the injury? What’s the difference in AMI?

Answer 20

The principal symptom is the pain of acute pericarditis, which usually develops 1–4 weeks after the cardiac injury but earlier (1–3 days) after AMI.

Question 21

Mechanism for the development of pyogenic pericarditis?

Answer 21

Pyogenic (purulent) pericarditis is usually secondary to cardiothoracic operations, by extension of infection from the lungs or pleural cavities, from rupture of the esophagus into the pericardial sac, or from rupture of a ring abscess in a patient with infective endocarditis.

Question 22

% of uremic patients that have pericarditis?

Answer 22

Pericarditis of renal failure occurs in up to onethird

of patients with chronic uremia (uremic pericarditis)

Question 23

What is dialysis-associated pericarditis?

Answer 23

patients undergoing chronic dialysis who have normal levels of blood urea and creatinine

Question 24

Neoplastic diseases that cause pericarditis?

Answer 24

(most commonly

carcinoma of the lung and breast, malignant melanoma, lymphoma, and leukemia

Question 25

Biggest cause of chronic pericardial effusions?

Answer 25

tuberculosis

Question 26

Causes of chronic pericardial effusions?

Answer 26

Myxedema, Neoplasms, SLE, rheumatoid arthritis, mycotic infections, radiation therapy to the chest, pyogenic infections, and chylopericardium

Question 27

Grossly sanguineous pericardial fluid.

Answer 27

neoplasm, tuberculosis, renal failure, or slow leakage from an aortic dissection

Question 28

Causes for chronic constrictive pericarditis?

Answer 28

tuberculosis, acute or relapsing viral or idiopathic pericarditis, trauma with organized blood clot, or cardiac surgery of any type or result from mediastinal irradiation, purulent infection, histoplasmosis, neoplastic disease (especially breast cancer, lung cancer, and lymphoma), rheumatoid arthritis, SLE, or chronic renal failure treated by chronic dialysis.

Question 29

What are the diseases that produce a ventricular pressure pulses like a “square root”?

Answer 29

restrictive cardiomyopathies; constrictive pericarditis

Question 30

Kussmaul’s sign occurs in which diseases?

Answer 30

chronic pericarditis but may also occur in tricuspid stenosis, right ventricular infarction, and restrictive cardiomyopathy

Question 31

Can you find a paradoxical pulse in chronic constrictive pericarditis?

Answer 31

A paradoxical pulse can be detected in about one-third

of cases.

Question 32

Broadbent’s sign

Answer 32

apical pulse is reduced and may retract in systole

Question 33

% of patients with chronic constritive pericarditis and atrial fibrillation.

Answer 33

Atrial fibrillation is present in about one-third of patients.

Question 34

Definitive treatment of constrictive pericarditis

Answer 34

Pericardial resection

Question 35

Pericardial resection mortality?

Answer 35

Operative mortality is in the range of 5 to 10% even in experienced centers

Question 36

Diseases that cause Subacute Effusive-Constrictive

Pericarditis?

Answer 36

tuberculosis, multiple attacks of acute idiopathic pericarditis, radiation, traumatic pericarditis, renal failure, scleroderma and neoplasms.

Question 37

Most common location of pericardial cysts?

Answer 37

Pericardial cysts appear as rounded or lobulated deformities of the cardiac silhouette, most commonly at the right cardiophrenic angle.

Question 38

Most common tumors involving the pericardium?

Answer 38

Tumors involving the pericardium are most commonly secondary to malignant neoplasms originating in or invading the mediastinum, including carcinoma of the bronchus and breast, lymphoma, and melanoma.

Question 39

Most common primary malignant tumor invading the pericardium?

Answer 39

Mesothelioma is the most common primary malignant

tumor.