Acute pericarditis, constrictive pericarditis and pericardial effusions

Question 1

causes of pericardial effusions:

Answer 1

idiopathic

viral - coxsackie bacterial, fungal, TB,

uremia- ESRD

hypothyroidism,

collagen vascular disease & autoimmune (SLE)

malignancy- lymphoma

post MI and trauma- Dressler syndrome

Question 2

what labs to order for work up for chronic pericardial effusion?

Answer 2

CBC, BMP, TSH, dsDNA, complement levels.

Question 3

if new onset heart failure, history of chest radiation and clear lungs think:

Answer 3

constrictive pericarditis

Question 4

causes of constrictive pericarditis

Answer 4

idiopathic

viral pericarditis

prior cardiac surgery

radiation therapy

tuberculous pericarditis (in endemic areas)

Question 5

clinical presentation of constrictive pericarditis

Answer 5

fatigue, dyspnea on exertion

peripheral edema,

ascites

increased JVP

pericardial knock may be heard

pulsus paradoxus

Kussmaul’s sign

Question 6

EKG findings of constrictive pericarditis

Answer 6

nonspecific, afib with low voltage QRS

Chest imaging may have pericardial thickening or calcification

Question 7

echocardiogram findings of constrictive pericarditis

Answer 7

see increased pericardial thickness

abnormal septal motion

biatrial enlargement pericardial thickness>4 mm

is suggestive of constrictive pericarditis

Question 8

Findings of constrictive pericarditis on right heart catherization

Answer 8

prominent x and Y descents, equalization of left and right ventricular end diastolic pressures

Question 9

right sided heart failure signs and elevated JVP and low voltage QRS on EKG and history of chest radiation, think

Answer 9

constrictive pericarditis

Question 10

what causes cardiac cirrhosis

Answer 10

long standing right sided heart failure.

Question 11

When do we get CT or cardiac MRI for evaluation of constrictive pericarditis?

Answer 11

get imaging to assess the extent of pericardial thickening and plan surgical resection in appropriately selected pts.

Question 12

acute pericarditis stage one will see these findings on EKG

Answer 12

diffuse concave upward ST segment elevation across percordial and limb leads with reciprocal ST depression in aVR and V1.

PR segment is elevated in aVR with depression in other limb leads.

Question 13

PR segment depressions is

Answer 13

very specific for acute pericarditis

Question 14

When do we see pathological ! waves

Answer 14

days or weeks after MI.

Question 15

what is this?

Answer 15

Evolution of acute pericarditis

Stage 1- seen a few hours and see diffuse concave upward ST segment and reciprocal ST depressions in leads aVR and V1 and see PR depressions

Stage 2: normalization of ST and PR segment and seen in first few days

Stage 3: presence of diffuse T wave inversions

Stage 4: normalization of the EKG or the persistence of T wave inversions over the next few weeks.

Question 16

treatment of acute pericarditis

Answer 16

high dose NSAIDs and colchicine 1.2mg daily in acute pericarditis.

ASA 650-1000 q6-8h

ibuprofen 400-800 mg q8h

indomethacin 50 mg q8h

NSAIDS should be tapered over next few weeks.

Do not give colchicine by itself as it’s not used that way. (also side effect of colchicine is diarrhea and neuropathy)

See pleuritic chest pain which is relieved by leaning forward and see diffuse ST elevation and depression of PR interval in limb and left percordial leads.

Question 17

features of acute pericarditis

Answer 17

Question 18

post pericardiotomy syndrome or PCIS) after recent cabg is from

Answer 18

surgical damage to the mesothelial pericardial cells and resultant blood in the pericardial space which creates a autoimmune reponse against the cardiac antigens.

These immune complexes can deposit and cause infalmmation into the lung, pericardium and pleura.

Question 19

presentation of postpericardiotomy syndrome

Answer 19

acute pericarditis, typical pleuritic chest pain, pericardial friction rub, and EG changes

may have a new or worsening pericardial effusion. EKG may be hard to interpret if they had an abnormal EKG to begin with.

Question 20

Treatment of post pericardiotomy syndrome (Dressler’s syndrome)

Answer 20

Tx with NSAIDS and steroids can be given in refractory cases

giving colchicine after cardiac surgery may decrease the incidence of PCIS

Question 21

when does post operative mediastinitis occur after CABG and what are the symptoms of presentation?

Answer 21

occur 1st two weeks after surgery

present with fever, tachycardia, chest pain and signs of sternal wound infection and purulent discharge.

Question 22

Graft occlusion occurs when

Answer 22

in first 30 days after CABG and typically present with postischemic symptoms.

See significant ECG abnormalities and ventiruclar arrhythmias and hemodynamic instability.

Pt is >4 weeks surgery is less likely.

Question 23

diagnostic criteria for pericarditis and myopericarditis

Answer 23

Question 24

what is myopericarditis?

Answer 24

this is acute pericarditis with myocardial inovlement as seen with elevated cardiac enzymes, myocarditis on cardiac MRI or newly depressed LV EF.

Pericarditis and myopericarditis have the same etiologies which is viral or idiopathic.

Question 25

Treatment of uncomplicated myopericarditis:

Answer 25

normal EF no arrhythmias

• treat same way as pericarditis:

NSAIDS (aspirin, indomethacin, ibuprofen) to control pain and reduce inflammation. IN post MI, aspirin is NSAID of choice as other NSAIDS inhibit formation of scar

Colchicine is recommend WITH NSAIDs to improve symptoms and decrease rate of recurrence.

Question 26

what should be avoided in pts wo have myopericarditis or pericarditis?

Answer 26

steroids or prednisone as this is associated with a higher rate of recurrence and only indicated in refractory pericarditis despite NSAID therapy.

also need to treat undelrying cause of pericarditis (autoimmune ,connective tissue disorder or ESRD)

Question 27

recent MI and pleuritic chest pain with radiation to the should and pericardial friction rub

Treatment for this condition?

Answer 27

peri-infarction pericarditis - seen within days of MI and seen in pts who do not get reperfusion. it is generally self limiting and will heal with higher doses of aspirin

Aspirin -650-1000 mg tid and continue plavix

Don’t give NSAIDs or steroids after recent MI because this can cause poor scar healing and scar thinning and lead to infarct expansion and myocardial free wall rupture.

NSAIDs are used in symptomatic relief in Dressler’s syndrome which happens weeks to months after acute MI.