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ICM > 3: Pericarditis > Flashcards

3: Pericarditis Flashcards

1
Q

how much fluid could the pericardium hold?

A

15-50 mL of plasma ultrafiltrate

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2
Q

most common cause of pericarditis

A

idiopathic

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3
Q

causes of pericarditis

A
  • radiation
  • neoplasm (primary, metastatic, paraneoplastic)
  • trauma
  • autoimmune (drug-induced lupus)
  • metabolic (hypothyroidism, uremia)
  • infectious
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4
Q

viral causes of pericarditis

A 
coxsackie B or A 
echovirus 
mumps 
adenovirus 
HIV
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5
Q

bacterial causes of pericarditis

A 
TB 
pneumococcus 
strep
staph 
legionella
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6
Q

fungal causes of pericarditis

A

histoplasmosis
coccidioidomycosis
candidiasis
blastomycosis

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7
Q

cardiac causes of pericarditis

A
  • early infarction pericarditis
  • late post cardiac injury (Dresslers)
  • myocarditis
  • dissecting aortic aneurysm
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8
Q

drugs that cause pericarditis (via drug-induced lupus)

A

procainamide
isoniazid
hydralazine

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9
Q

acute pericarditis- pathogenesis

A
  • usually fluid accumulation - commonly serous
  • bacteria or tumor cells
  • sometimes purulent if bacterial
  • fluid may resolve or form adhesions
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10
Q

clinical features of pericarditis

A

chest pain
pericardial friction rub
EKG changes
pericardial effusion

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11
Q

chief complaint with acute pericarditis

A 
chest pain unrelated to exertion 
fatigue 
dyspnea
malaise 
fever
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12
Q

describe the chest pain of pericarditis

A

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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13
Q

what does a pericardial friction rub sound like?

A
  • 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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14
Q

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

A

pt sitting upright, leaning forward w/ diaphragm over LSB

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15
Q

what does CXR look like in pericarditis?

A

usually normal

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16
Q

when will you see EKG changes in pericarditis?

A

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

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17
Q

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

A

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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18
Q

acute pericarditis EKG

A

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

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19
Q

other options in acute pericarditis ddx

A 
ACS 
myocarditis 
pleurisy 
pneumonia 
PE 
aortic dissection 
pneumothorax 
musculoskeletal pain 
esophageal pain
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20
Q

complications of acute pericarditis

A

pericardial effusion and tamponade
constrictive pericarditis (late)
relapse

21
Q

medical therapy - idiopathic and viral pericarditis

A

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

22
Q

medical therapy - pericarditis post acute MI

A

aspirin and colchicine

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

23
Q

contraindications for using colchicine

A

severe renal or liver disease
blood dyscrasias
GI motility disorders

24
Q

3 instances where you would use glucocorticoids for pericarditis

A
  1. refractory symptoms
  2. due to CT disease
  3. uremic pericarditis
25
Q

how do you treat tamponade or suspected purulent pericarditis?

A

pericardiocentesis

26
Q

what other treatment do you add for uremic pericarditis?

A

intensified hemodialysis

27
Q

causes of pericardial effusion

A 
acute pericarditis 
radiation 
malignancy 
cardiac perforation 
hypothyroidism 
CT disease 
post-MI/heart surgery 
chronic renal failure 
aortic dissection
28
Q

EKG changes seen in pericardial effusion

A

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

29
Q

presentation of pericardial tamponade

A

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

30
Q

what is pulsus paradoxus

A

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

31
Q

how to check for pulsus paradoxus

A

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

32
Q

physical findings in pericardial tamponade

A 
sinus tachycardia 
tachypnea 
hypotension (late) w/ narrow pulse pressure 
elevated JVP with loss of Y descent 
edema 
pulsus paradoxus
33
Q

3 EKG findings of pericardial tamponade

A

sinus tachycardia
low voltage
electrical alternans

34
Q

what tests should you order to evaluate pericardial tamponade?

A

emergent echocardiogram w/ doppler

right heart cath( equalization of pressures)

35
Q

treatment of pericardial tamponade

A 
MEDICAL EMERGENCY 
IV fluids (temporizing) 
vasopressors, as needed 
prompt pericardiocentesis 
percardial window
36
Q

what should you avoid during treatment of pericardial tamponade

A

diuretics

vasodilators

37
Q

describe pericardial fluid analysis

A
  • 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
38
Q

labs to get with pericarditis

A 
cardiac enzymes 
inflammation markers (CRP, ESR, WBC) 
thyroid function
renal function 
body fluid cultures 
TB skin test
39
Q

describe pathophysiology of constrictive pericarditis

A
  • 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
40
Q

etiology of constrictive pericarditis

A
  • idiopathic or viral (most)
  • post cardiac surgery
  • radiation therapy
  • CT disease
  • post TB, bacterial
41
Q

presentation of constrictive pericarditis

A
  • slow, indolent

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

42
Q

what is constrictive pericarditis often misdiagnosed as?

A

cirrhosis

43
Q

physical findings in constrictive pericarditis

A
  • elevated JVP w/ prominent X and Y descents
  • Kussmaul’s sign
  • pericardial knock
  • systemic congestion( hepatomegaly, ascites, edema)
44
Q

what is Kussmaul’s sign

A

lack of an inspiratory decline in JVP

45
Q

contrast jugular venous waveform in pericardial tamponade and constrictive pericarditis

A

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

46
Q

what will CXR show in constrictive pericarditis?

A

pericardial calcification

47
Q

what will chest CT show in constrictive pericarditis?

A

pericardial thickening

48
Q

therapy for constrictive pericarditis

A

diuretics

pericardial stripping

ICM (26 decks)

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