8/21- Pericardial Diseases at the Bedside Flashcards
Case)
- 65 yo woman admitted with progressively increasing abdominal girth and leg swelling of 5 mo duration
- Not previously known to have any cardiac disease
- PMH: Hodgkin’s lymphoma diagnosed at 48 yo for which she received radiation therapy to chest, mediastinum, and abdomen (cured since without recurrence)
- BP = 114/86 (with decrease in SBP of 7 mmHg during normal inspiration)
- HEENT: distended jugular veins to 8 cm above Angle of Lewis with prominent steep early diastolic y descent; jugular veins did not collapse during inspiration
- Chest: clear lungs, quiet precordium with decreased S1 and S2, no murmurs. Possible early disatolic extrasound after S2 (no change with inspiration)
- Positive fluid waves in abdomen, large liver (nontender)
- 2+ pitting ankle and pretibial edema, no cyanosis, minimal clubbing
- Normal sinus rhythm on EKG
This pt has a clinical presentation consistent with:
A. Congestive heart failure
B. Gross volume overload
C. Evidence of chronically elevated RA pressures
D. All of the above
This pt has a clinical presentation consistent with:
A. Congestive heart failure
B. Gross volume overload
C. Evidence of chronically elevated RA pressures
D. All of the above
What is/are common cause(s) of such a clinical presentation in an elderly pt in practice?
A. CHF due to CAD
B. CHF due to dilated cardiomyopathy
C. CHF due to longstanding HTN
D. Any of the above
What is/are common cause(s) of such a clinical presentation in an elderly pt in practice?
A. CHF due to CAD
B. CHF due to dilated cardiomyopathy
C. CHF due to longstanding HTN
D. Any of the above
What is the mechanism of a 7 mmHg drop in SBP with inspiration in this pt?
A. Decline in LV filling with septal bulging
B. Decline in RV filling with septal bulging
C. Lower LV SV
D. Lower SVR
E. A and C
What is the mechanism of a 7 mmHg drop in SBP with inspiration in this pt?
A. Decline in LV filling with septal bulging
B. Decline in RV filling with septal bulging
C. Lower LV SV
D. Lower SVR
E. A and C
What is a pulsus paradoxus?
A. Paradoxical loss of pulse during inspiration
B. Drop in SBP > 10 mmHg during inspiration
C. Decrease in SBP under 10 mmHg during inspiration
D. None of the above
What is a pulsus paradoxus?
A. Paradoxical loss of pulse during inspiration
B. Drop in SBP > 10 mmHg during inspiration
C. Decrease in SBP under 10 mmHg during inspiration
D. None of the above
Why did the jugular veins fail to collapse during inspiration?
A. Very high RA pressure prevents jugular vein emptying into RA
B. Restricted filling of the RV markedly raises the RA pressure
C. A and B
D. None of the above
Why did the jugular veins fail to collapse during inspiration?
A. Very high RA pressure prevents jugular vein emptying into RA
B. Restricted filling of the RV markedly raises the RA pressure
C. A and B
D. None of the above
What is the name of the sign regarding failure of the JV to collapse?
A. Pulsus paradoxus
B. Pulsus alternans
C. Kussmaul sign
D. Electrical alternans
E. Stubborn JV sign
What is the name of the sign regarding failure of the JV to collapse?
A. Pulsus paradoxus
B. Pulsus alternans
C. Kussmaul sign
D. Electrical alternans
E. Stubborn JV sign
What causes the y-descent of the JV or RA pressure waveform?
A. Late ventricular filling
B. Early ventricular filling
C. Diastasis or slow ventricular filling
D. Isovolumic relaxation (IVR)
What causes the y-descent of the JV or RA pressure waveform?
A. Late ventricular filling
B. Early ventricular filling
C. Diastasis or slow ventricular filling
D. Isovolumic relaxation (IVR)
What causes the STEEP y-descent in this patient?
A. Enhanced very early RV filling
B. Impaired early RV filling
C. Enhanced very early RA emptying
D. A and C
E. None of the above
What causes the STEEP y-descent in this patient?
A. Enhanced very early RV filling
B. Impaired early RV filling
C. Enhanced very early RA emptying
D. A and C
E. None of the above
What does x-descent mark in the atrial pressure waveform?
What does a steep x-descent result from?
X-descent: atrial relaxation
- Steep in pericardial disease
- Steep x-descent results from an elevated JVP
What causes the dip-and-plateau sign?
A. Enhanced very early filling followed by sudden halt in filling
B. Decreased very early RV filling followed by compensatory increased filling
C. None of the above
What causes the dip-and-plateau sign?
A. Enhanced very early filling followed by sudden halt in filling
B. Decreased very early RV filling followed by compensatory increased filling
C. None of the above
- Dip = enhanced early RV filling
- Plateau = reduced late RV filling
Do you expect a dip-and-plateau in this patient?
Yes
What is the most likely underlying cardiac disease to explain this patient’s presentation?
A. Cardiac tamponade
B. Constrictive pericarditis
C. CHF due to CAD/HTN
D. DCM
What is the most likely underlying cardiac disease to explain this patient’s presentation?
A. Cardiac tamponade
B. Constrictive pericarditis
C. CHF due to CAD/HTN
D. DCM
What is causing the early diastolic extra sound in this patient?
A. Loud P2
B. Loud S3 gallop
C. Prominent S4 gallop
D. Tumor plop
E. Pericardial knock
What is causing the early diastolic extra sound in this patient?
A. Loud P2
B. Loud S3 gallop
C. Prominent S4 gallop
D. Tumor plop
E. Pericardial knock
- Early diastolic extra sound (K)
- Occurs shortly after S2 (may be confused with S3 gallop)
- Results from abrupt cessation or slowing of ventricular filling as the stiff pericardium limits expansion of the ventricle
Case 2)
- 43 yo woman
- Chronic smoker
- Admitted for SOB, weakness, and progressive weight loss of about 25 pounds in the last 3 mo
- 2 ya, diagnosed with stage III breast adenocarcinma and received 6 courses of chemo with good symptomatic response and drastic reduction in tumor mass. Complete remission could not be achieved
- PE: pale, weak, cachectic in mild distress
- BP = 85/55; no change during inspiration
- HR = 130/min (tachycardia)
- RR = 26/min
- Dry mucous membranes, decreased skin turgor, and pale conjunctiva
- HEENT: palpable hard supraclavicular and axillary LNs; normal carotid upstrokes. Markedly distended neck veins with steep x-descent and normal y-descent
- Clear lungs
- Quiet precordium with markedly decreased S1 and S2; no extrasounds
- ECG: NSR, fat rate, alternating large and small QRS complexes; decreased QRS complexes throughout
What is the most likely cardiac disease in this patient?
A. Constrictive pericarditis
B. Cardiac tamponade
C. Heart failure
D. Dilated cardiomyopathy
E. Pericardial metastasis
What is the most likely cardiac disease in this patient?
A. Constrictive pericarditis
B. Cardiac tamponade
C. Heart failure
D. Dilated cardiomyopathy
E. Pericardial metastasis
Do you expect to detect > 10 mmHg drop in SBP during inspiration?
No; while this (pulsus paradoxus) is a hallmark of cardiac tamponade, it may not be seen in hypotensive pts like this one
- IV dependence -> shift of IV septum to LV with increased RV filling during inspiration -> Reduced LV EDV and SV (Frank Starling) and thus decreased SBP
What causes electrical alternans?
A. Swinging motion of the heart within the fluid-filled pericardial sac
B. Swinging motion of the pericardial fluid around the heart
C. Alternation of QRS complexes
D. A and C
What causes electrical alternans?
A. Swinging motion of the heart within the fluid-filled pericardial sac
B. Swinging motion of the pericardial fluid around the heart
C. Alternation of QRS complexes
D. A and C
… probably a better answer than C since C isn’t a cause
- Electrical alternans is the alternating amplitude of the R wave from one complex to the next
What is the classic triad of acute pericarditis?
- Sharp chest pain of pericarditis by Hx
- Diffuse ST elevation by ECG
- Pericardial rub sound by physical exam
