3: Pericarditis Flashcards
how much fluid could the pericardium hold?
15-50 mL of plasma ultrafiltrate
most common cause of pericarditis
idiopathic
causes of pericarditis
- radiation
- neoplasm (primary, metastatic, paraneoplastic)
- trauma
- autoimmune (drug-induced lupus)
- metabolic (hypothyroidism, uremia)
- infectious
viral causes of pericarditis
coxsackie B or A echovirus mumps adenovirus HIV
bacterial causes of pericarditis
TB pneumococcus strep staph legionella
fungal causes of pericarditis
histoplasmosis
coccidioidomycosis
candidiasis
blastomycosis
cardiac causes of pericarditis
- early infarction pericarditis
- late post cardiac injury (Dresslers)
- myocarditis
- dissecting aortic aneurysm
drugs that cause pericarditis (via drug-induced lupus)
procainamide
isoniazid
hydralazine
acute pericarditis- pathogenesis
- usually fluid accumulation - commonly serous
- bacteria or tumor cells
- sometimes purulent if bacterial
- fluid may resolve or form adhesions
clinical features of pericarditis
chest pain
pericardial friction rub
EKG changes
pericardial effusion
chief complaint with acute pericarditis
chest pain unrelated to exertion fatigue dyspnea malaise fever
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
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
in what position do you listen for a pericardial friction rub?
pt sitting upright, leaning forward w/ diaphragm over LSB
what does CXR look like in pericarditis?
usually normal
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
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
acute pericarditis EKG
sinus tachycardia
diffuse concave ST elevations
PR segment depression
PR elevation and ST depression in aVR
other options in acute pericarditis ddx
ACS myocarditis pleurisy pneumonia PE aortic dissection pneumothorax musculoskeletal pain esophageal pain
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
