3: Pericarditis Flashcards by Katie Hutchins

how much fluid could the pericardium hold?

15-50 mL of plasma ultrafiltrate

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most common cause of pericarditis

idiopathic

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causes of pericarditis

radiation
neoplasm (primary, metastatic, paraneoplastic)
trauma
autoimmune (drug-induced lupus)
metabolic (hypothyroidism, uremia)
infectious

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viral causes of pericarditis

coxsackie B or A 
echovirus 
mumps 
adenovirus 
HIV

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bacterial causes of pericarditis

TB 
pneumococcus 
strep
staph 
legionella

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fungal causes of pericarditis

histoplasmosis
coccidioidomycosis
candidiasis
blastomycosis

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cardiac causes of pericarditis

early infarction pericarditis
late post cardiac injury (Dresslers)
myocarditis
dissecting aortic aneurysm

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drugs that cause pericarditis (via drug-induced lupus)

procainamide
isoniazid
hydralazine

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acute pericarditis- pathogenesis

usually fluid accumulation - commonly serous
bacteria or tumor cells
sometimes purulent if bacterial
fluid may resolve or form adhesions

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clinical features of pericarditis

chest pain
pericardial friction rub
EKG changes
pericardial effusion

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chief complaint with acute pericarditis

chest pain unrelated to exertion 
fatigue 
dyspnea
malaise 
fever

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describe the chest pain of pericarditis

more common with infectious etiology
less common with uremia/rheumatologic etiology
sudden onset
anterior chest wall
sharp, pleuritic in nature
worse when lying flat, inspiring, or coughing
better when seated, leaning forward

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what does a pericardial friction rub sound like?

scratchy, leathery sound - higher pitch than diastolic filling sounds
most often triphasic, can be biphasic
can come and go, vary in intensity

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in what position do you listen for a pericardial friction rub?

pt sitting upright, leaning forward w/ diaphragm over LSB

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what does CXR look like in pericarditis?

usually normal

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when will you see EKG changes in pericarditis?

only when it is bad enough to cause inflammation of the epicardium, because pericardium itself is electrically inert

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what changes will you see on EKG in pericarditis? 4 stages

1: (h-d) diffuse ST elevation, concave up, and PR depression
2: (1w) normalization of ST and PR segments
3: diffuse T wave inversions, after ST segments have become isoelectric
4: normalization or indefinite T wave inversions

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acute pericarditis EKG

sinus tachycardia
diffuse concave ST elevations
PR segment depression
PR elevation and ST depression in aVR

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other options in acute pericarditis ddx

ACS 
myocarditis 
pleurisy 
pneumonia 
PE 
aortic dissection 
pneumothorax 
musculoskeletal pain 
esophageal pain

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complications of acute pericarditis

pericardial effusion and tamponade
constrictive pericarditis (late)
relapse

medical therapy - idiopathic and viral pericarditis

combination of NSAIDS (indomethacin, ibuprofen 2w) and colchicine (3mo)

medical therapy - pericarditis post acute MI

aspirin and colchicine

*avoid NSAIDS since they may interfere with healing and scar formation

contraindications for using colchicine

severe renal or liver disease
blood dyscrasias
GI motility disorders

3 instances where you would use glucocorticoids for pericarditis

refractory symptoms
due to CT disease
uremic pericarditis

how do you treat tamponade or suspected purulent pericarditis?

pericardiocentesis

what other treatment do you add for uremic pericarditis?

intensified hemodialysis

causes of pericardial effusion

``` acute pericarditis radiation malignancy cardiac perforation hypothyroidism CT disease post-MI/heart surgery chronic renal failure aortic dissection ```

EKG changes seen in pericardial effusion

electrical alternans (because heart is swaying back and forth in the fluid filling pericardium)

presentation of pericardial tamponade

depends on chronicity of process 'CHF' symptoms with clear lungs unexplained signs of right heart failure (edema, high JVP) new cardiomegaly on CXR sinus tachycardia, low voltage, electrical alternans on EKG

what is pulsus paradoxus

fall of systolic blood pressure of more than 10mmHg with inspiration inspiration increases venous inflow to RV, RV free wall cannot expand, inspiratory increase in VR causes septal shift impinging on LV volume, diminished stroke volume with inspiration

how to check for pulsus paradoxus

lower BP cuff to where you first hear systolic, you won't hear many - then lower again, hear more - then lower again, you'll hear most of the beats

physical findings in pericardial tamponade

``` sinus tachycardia tachypnea hypotension (late) w/ narrow pulse pressure elevated JVP with loss of Y descent edema pulsus paradoxus ```

3 EKG findings of pericardial tamponade

sinus tachycardia low voltage electrical alternans

what tests should you order to evaluate pericardial tamponade?

emergent echocardiogram w/ doppler | right heart cath( equalization of pressures)

treatment of pericardial tamponade

``` MEDICAL EMERGENCY IV fluids (temporizing) vasopressors, as needed prompt pericardiocentesis percardial window ```

what should you avoid during treatment of pericardial tamponade

diuretics | vasodilators

describe pericardial fluid analysis

- Gram stain + bacterial/fungal culture - cytology - AFB stain and mycobacterial culture w/ adenosine deaminase, IGN-g, or lysozyme (for TB pericarditis) - PCR - protein, LDH, glucose, RBC, WBC

labs to get with pericarditis

``` cardiac enzymes inflammation markers (CRP, ESR, WBC) thyroid function renal function body fluid cultures TB skin test ```

describe pathophysiology of constrictive pericarditis

- chronic thickening/scarring of pericardium leads to encasement of heart and impaired diastolic filling of LV and RV - early diastolic filling unimpaired though**** - chambers expand and collide with unyielding pericardium which halts further diastolic filling - 'dip and plateau' or 'square root' sign

etiology of constrictive pericarditis

- idiopathic or viral (most) - post cardiac surgery - radiation therapy - CT disease - post TB, bacterial

presentation of constrictive pericarditis

- slow, indolent | - unexplained right heart failure (systemic congestion, fatigue, dyspnea)

what is constrictive pericarditis often misdiagnosed as?

cirrhosis

physical findings in constrictive pericarditis

- elevated JVP w/ prominent X and Y descents - Kussmaul's sign - pericardial knock - systemic congestion( hepatomegaly, ascites, edema)

what is Kussmaul's sign

lack of an inspiratory decline in JVP

contrast jugular venous waveform in pericardial tamponade and constrictive pericarditis

tamponade: loss of Y descent constrictive: prominent X and Y descents

what will CXR show in constrictive pericarditis?

pericardial calcification

what will chest CT show in constrictive pericarditis?

pericardial thickening

therapy for constrictive pericarditis

diuretics | pericardial stripping