B P9 C86 Pericardial Diseases Flashcards
The pericardium is composed of two layers, the _____, a monolayer of mesothelial cells and collagen and elastin fibers adherent to the epicardial surface of the heart, and the _____, which is normally about 2 mm thick and surrounds most of the heart
Visceral pericardium
Fibrous parietal pericardium
The _____ pericardium is largely acellular and contains collagen and elastin fibers
Parietal
The _____ pericardium reflects back near the origins of the great vessels and is continuous with and forms the inner layer of the parietal pericardium.
Visceral
The pericardial space or sac is contained within these two layers, and normally contains up to _____ of serous fluid.
50 mL
While its removal has no obvious negative consequences, the pericardium does function:
(1) to maintain a relatively constant position of the heart in the thorax
(2) provides a barrier to infection
The best-characterized mechanical function of the pericardium is its _____. This reflects the mechanical properties of the parietal pericardium.
Restraining effect on cardiac volume
In developing regions where _____ is endemic, it is the most common cause of pericarditis and effusion.
TB
In developed countries, presumed _____ etiologies are most common
Viral and idiopathic
Idiopathic cases of acute pericarditis are presumed to be _____.
Viral
Cases of acute pericarditis with concomitant myocarditis with impaired function are labeled _____
Perimyocarditis
Cases of acute pericarditis with concomitant myocarditis with normal LV function are labeled _____
Myopericarditis
In greater than 90% of cases, the main symptom of acute pericarditis is _____, often quite severe
Chest pain
Classically, the pain of acute pericarditis radiates to the _____.
Trapezius ridge
The pathognomonic physical sign of acute pericarditis is the _____, reported in about one third of cases.
Friction rub
The classic rub consists of three components corresponding to _____, and can be likened to the sound made when walking on crunchy snow.
Ventricular systole
Early diastole
Atrial contraction
The _____ is a key test for diagnosing acute pericarditis
ECG
The classic finding in the ECG of patients with acute pericarditis is _____
Diffuse ST-segment elevation.
The ST-segment vector points leftward, anterior, and inferior, with ST-segment elevation in all leads except aVR and often V1
The distinction between acute pericarditis and transmural ischemia is usually not difficult because of _____.
(1) More extensive lead involvement
(2) Lack of evolution to pathologic Q waves in pericarditis
(3) More prominent reciprocal ST depression in ischemia
_____ is also common and considered the earliest ECG sign of acute pericarditis, reflecting pericardial involvement overlying the atria
PR-segment depression
Typical ECG evolution in acute pericarditis follows four stages: _____ The ECG often evolves without all four stages
(1) PR depression and/or diffuse ST segment elevation
(2) Normalization of ST segment
(3) T wave inversion with or without ST segment depression
(4) Normalization
In acute pericarditis, additional ECG changes that may constitute clues to the cause of pericarditis or associated findings include _____ in Lyme disease, _____signifying a previous, silent MI, and _____ pointing toward significant effusion.
Lyme disease: AV block
Previous /silent MI: Pathologic Q waves
Significant effusion: Low-voltage or electrical alternans
In acute pericarditis, CRP usually normalizes within _____
1 week and in almost all cases by 4 weeks after initial evaluation
In addition to aiding in diagnosis, ___ can be used to monitor disease activity and individualize duration of therapy
CRP
Because small to moderate effusions may not cause an abnormal cardiac silhouette, even modest cardiac enlargement is of concern and generally associated with an effusion greater than _____ mL.
300 mL
The echocardiographic-Doppler examination is completely normal in approximately __% of patients with acute pericarditis
40%
Semiquantitative echocardiographic measurements of pericardial effusions
<10mm: small
10-20mm: moderate
>20: large
An _____ in a patient with a history consistent with acute pericarditis is confirmatory of the diagnosis.
Effusion
According to the guidelines, the clinical diagnosis of acute pericarditis requires at least two of the following:
(1) chest pain
(2) pericardial friction rub
(3) ECG changes consisting of typical ST elevation and/or PR depression
(4) pericardial effusion
In acute pericarditis, CT may show _____. CMR may show _____.
CT: thickening or hyperattenuation of the pericardium
CMR: pericardial edema based on fat-suppressed T2-weighted dark blood images, or delayed pericardial hyperenhancement indicative of ongoing inflammation
Although usually considered a hallmark of pericarditis, typical ECG changes reflect concomitant involvement of the _____,because the pericardium is electrically silent.
Myocardium
In patients suspected of acute pericarditis, the recommended routine tests are the following:
ECG, CBC, serum creatinine, CRP (or hsCRP), cardiac troponin, chest radiograph, and echocardiogram.
If laboratory data do not contradict the diagnosis of idiopathic pericarditis, symptomatic treatment with _____ is recommended
Nonsteroidal Antiinflammatory Drugs (NSAIDs)
In patients with acute pericarditis, restriction of physical activity _____ is recommended.
Until resolution of symptoms and normalization of CRP occurs
For athletes who had acute pericarditis, return to sports is recommended after an arbitrary term of ___ months and only after symptoms have fully resolved and CRP, ECG, and echocardiogram have normalized
3 months
In the treatment of acute pericarditis, two alternative regimens with an excellent safety profile are recommended:
Ibuprofen 600 to 800 mg orally TID
ASA 750 to 1000 mg orally TID
Colchicine is recommended for ___ months as an adjunct to NSAIDs.
3 months
Colchicine is thought to exert an antiinflammatory effect by blocking microtubule assembly in WBCs and inhibiting the inflammasome. Weight-adjusted doses _____ are recommended
0.5 to 0.6 mg orally every 12 hours
or
0.5 to 0.6 mg once daily for patients <70 kg
Predictors of poor prognosis in acute pericarditis:
Major
* Fever > 38 ̊C
* Subacute onset
* Large pericardial effusion
* Cardiac tamponade
* Lack of response to aspirin or NSAIDs
after at least 1 week of therapy
Minor
* Myopericarditis
* Immunosuppression
* Trauma
* Oral anticoagulant therapy
Corticosteroid use should be minimized in patients with acute pericarditis because they may impair the clearance of infectious agents and short, high-dose courses may increase the risk of recurrence. However, there are selected indications for their use:
(1) contraindications to or failure of NSAID/colchicine
(2) underlying conditions (e.g., autoimmune diseases) whose primary treatment is corticosteroids
(3) concomitant diseases (e.g., renal failure)
(4) pregnancy
(5) concomitant therapies constituting relative contraindications to NSAIDs and/or colchicine (e.g., oral anticoagulants)
When cortecosteroids are used, relatively low doses of corticosteroids are recommended _____ to minimize complications.
Prednisone 0.2 to 0.5 mg/kg daily
Recurrences occur in _____% of patients with idiopathic acute pericarditis
15-30%
A diagnosis of recurrent pericarditis requires new symptoms and signs of disease activity (friction rub, ECG changes, new or worsening pericardial effusion, elevation of CRP) after a symptom-free interval of at least _____ weeks.
4-6 weeks
If NSAID + Colchicine therapy fails in recurrent pericarditis, _____ may replace NSAID or may be added as “triple therapy”.
Corticosteroids
Colchicine should be included for ____ for difficult cases of recurrent pericarditis.
At least 6 mo up to 12 months
Potential alternative therapies for colchicine-resistant and corticosteroid -dependent recurrent pericarditis include:
(1) Azathioprine (1 mg/kg/day with gradual dose increases and monitoring of WBC, transaminases, and amylase)
(2) Human IVIg (400 to 500 mg/kg/day for 5 days with a possible repeat course after 1 month)
(3) Anakinra, a recombinant short-acting IL-1α and IL-1β cytokine receptor blocker, which is off-label, is one example (1 to 2 mg/kg/day up to 100 mg SC daily)
(4) Rilonacept (loading dose of 320 mg SC followed by 160 mg SC weekly)
Effusions with a high likelihood of progression to tamponade include:
Bacterial
HIV-associated infections
Bleeding
Neoplastic disease
The mechanical consequences of a high pressure acting on the surface of the heart mainly result from compression and collapse of the _____ heart.
Right Heart
The limited pericardial reserve volume dictates that modest amounts of rapidly accumulating fluid (_____mL) can impair cardiac function.
150 to 200 mL
The compensatory response to a hemodynamically significant effusion includes _____
Increased adrenergic tone and parasympathetic withdrawal
As fluid accumulates, left- and right-sided atrial and ventricular diastolic pressures rise and in severe tamponade equalize at a pressure similar to that in the pericardial sac, typically _____ mm Hg
20-25 mm Hg
Equalization of atrial and ventricular diastolic pressures is closest during ____.
Inspiration
The small ______ (decreased preload) mainly accounts for reduced stroke volume (SV).
End-diastolic ventricular volume
Hemodynamic abnormalities characteristic of tamponade:
(1) Elevated and equal intra-cavitary filling pressures
(2) Low transmural filling pressures
(3) Small cardiac volumes
(4) Loss of y descent of RA or venous pressure wave
(5) Paradoxical pulse
Loss of the y descent has been explained based on the concept that _____ in severe tamponade
Total heart volume is fixed
The second characteristic finding in tamponade is the _____, an abnormally large drop (>10 mm Hg) in systolic arterial pressure during inspiration.
Paradoxical pulse
Other causes of pulsus paradoxus include:
CP
Pulmonary embolus
Pulmonary disease with large variations in intra-thoracic pressure
In tamponade, in contrast to constriction, the normal inspiratory increase in systemic venous return is present and the normal inspiratory decline in systemic venous pressure is retained (Kussmaul’s sign is _____).
Absent
In tamponade, the interventricular septum shifts to the left in exaggerated fashion on _____, encroaching on the LV such that SV and pressure generation are further reduced.
Inspiration
When there are preexisting elevations in diastolic pressures and/or volume, tamponade can occur without a paradoxical pulse. Examples include:
Chronic LV dysfunction
Aortic regurgitation
Atrial septal defect
In patients with retrograde bleeding into the pericardial sac due to aortic dissection,4 tamponade may occur without a paradoxical pulse because of:
Aortic valve disruption and regurgitation
Although mean left- and right-sided filling pressures are typically 20 to 25 mm Hg, tamponade can occur at lower filling pressures, that is, _____.
Low-pressure tamponade
Low-pressure tamponade often occurs when there is a decrease in _____ in the setting of a preexisting effusion which would not otherwise be significant.
Blood volume
Low-pressure tamponade may be observed during:
(1) Hemodialysis
(2) in patients with blood loss and volume depletion
(3) when diuretics are administered to patients with effusions
Pericardial effusions can be loculated or localized, resulting in regional tamponade, most commonly after _____.
Cardiac surgery
_____ should be considered whenever there is hypotension in a setting where a loculated effusion is present
Regional tamponade
Patients with tamponade often complain of _____ (the mechanism is uncertain because there is no pulmonary congestion) and are more comfortable sitting forward
Dyspnea
Beck’s triad, _____ suggests severe tamponade.
Hypotension
Muffled heart sounds,
Elevated jugular venous pressure
In tamponade, tachycardia is also the rule unless:
(1) heart rate lowering drugs have been administered
(2) conduction system disease coexists
(3) pre-terminal bradycardic reflex has supervened
Hemodynamics in cardiac tamponade:
Systemic venous wave morph.: Absent y descent
Inspiratory change in SVP: DECREASE
Square root sign: ABSENT
Paradoxical pulse: Usually present
Equal left/right filling: Present
Hemodynamics in constrictive pericarditis vs cardiac tamponade:
Systemic venous wave morph.: prominent y descent (M or W shaped)
Inspiratory change in SVP: Increase or no change (Kussmaul sign)
Square root sign: PRESENT
Paradoxical pulse: Present in 1/3
Equal left/right filling: Present
This ECG finding in tamponade is nonspecific and can be caused by emphysema, infiltrative myocardial disease, and pneumothorax.
Reduced voltage
This ECG finding in tamponade is specific but relatively insensitive and caused by anterior-posterior swinging of the heart with each contraction.
Electrical alternans
The chest radiograph in patients with pericardial effusion reveals a normal cardiac silhouette until effusions are at least _____ in size.
Moderate
A significant effusion appears as a lucent separation between parietal and visceral pericardium for the entire _____.
Cardiac cycle
Small effusions are usually first evident over the _____LV. With increasing effusions, the fluid spreads anteriorly, laterally, and behind the LA, where it is limited by the visceral pericardial reflection
Small: Posterobasal LV
Increaseing: anterior - lateral- behind LA
Effusions are graded as:
Trivial (only seen in systole)
Small (echo free space in diastole <10 mm)
Moderate (10 to 20 mm)
Large (>20 mm)
Very large (>25 mm)
Frond-like or shaggy appearing structures in the pericardial space on echocardiography suggest:
Clots
Chronic inflammation
Neoplastic processes
Several echocardiographic findings indicate that an effusion is large enough to cause hemodynamic compromise. These include:
(1) Early diastolic collapse of RV
(2) Late diastolic indentation or collapse of RA
(3) Exaggerated respiratory variation in RV and LV size and interventricular septal shifting during inspiration (septal bulge or “bounce”)
Isolated LV and LA chamber collapse can occur with pericardial hematomas after _____.
Cardiac surgery
Doppler recordings in patients with tamponade demonstrate:
(1) exaggerated respiratory variation in right- and left-sided venous and valvular flow
(2) inspiratory increases on the right and decreases on the left
_____ provide more detailed quantitation and regional localization of effusions than echocardiography and are useful with loculated and coexistent pleural effusions
CT and MRI
CT Attenuation similar to water suggests _____; attenuation denser than water suggests _____ ;and attenuation less dense than water,a _____ effusion.
Water: Transudative effusion
Denser than water: Malignant, bloody or purulent
Less dense than water: Chylous
Situations where tamponade is a near-term threat include:
(1) Suspected bacterial pericarditis
(2) Hemopericardium
(3) Any moderate to large effusion that is not thought to be chronic and/or is increasing in size
Klein and colleagues propose a three-step scoring system for pericardial effusion that awards points based on _____to arrive at a cumulative score whose value dictates whether urgent drainage is warranted.
Etiology
Clinical presentation
Imaging
Patients with _____ should be considered to have threatened tamponade because of the etiology.
(1) Suspected bacterial infections
(2) Hemopericardium with small effusions (<10 mm)
Patients with acute, apparently idiopathic pericarditis with no more than mild tamponade can be treated for a brief period of time under careful monitoring with an _____ in an attempt to rapidly shrink the effusion.
NSAID and/ or a corticosteroid combined with colchicine
Once actual or threatened tamponade is diagnosed, _____ should be instituted.
IV hydration with normal saline
_____ increase the risk and difficulty of closed pericardiocentesis.
Loculated effusions or effusions containing clots or fibrinous material
The danger of a closed approach pericardiocentesis in patients with hemopericardium is that _____ without affording an opportunity to correct its source
Lowering intra-pericardial pressure will allow more bleeding
In cases of trauma or post-MI LV rupture, closed pericardiocentesis should usually be avoided.
If bleeding is slower, closed pericardiocentesis is generally indicated because bleeding may stop spontaneously and/or the procedure can provide temporary relief before definitive repair.
Closed pericardiocentesis in patients with hemopericardium due to _____ has been considered contraindicated.
Type A Aortic dissection
The usual approach to closed pericardiocentesis is _____ needle insertion with echocardiographic guidance to minimize risks of myocardial puncture and assess completeness of fluid removal
Para-apical
During pericardiocentesis, once the needle has entered the pericardial space, a modest amount of fluid is removed (perhaps _____ mL) in an effort to produce rapid improvement
50-100
Echocardiographically guided pericardiocentesis has a greater than ___% success rate and less than ___% serious complication rate
95% Success rate
<2% Serious complication rate
Rarely, patients suffer _____ following closed or open drainage, a poorly understood but life-threatening syndrome characterized by combinations of pulmonary edema and shock.
Pericardial decompression syndrome
If a pulmonary artery catheter has been inserted,_____ should be monitored before, during, and after the procedure.
RA and pulmonary capillary wedge pressure and CO
Intra-pericardial catheters should ideally be left in place for ____ days to allow continued drainage and minimize recurrence
2-3 days
Cholesterol-rich (“gold paint”) effusions occur in _____.
Hypothyroidism
Chylous effusions can occur after ____.
Traumatic or surgical injury to the thoracic duct
Or
Obstruction by neoplasms
If TB pericarditis is suspected, several other tests are useful, including:
Unstimulated interferon-gamma (uIFN-γ)
Adenosine deaminase (ADA)
Lysozyme levels
Polymerase chain reaction (PCR)
In a small study, _____ antibodies in pericardial fluid and serum were found to be predictive of recurrence in patients with chronic effusions
Anti-myolemmal
_____ is the end stage of an inflammatory process involving the pericardium.
Constrictive pericarditis
In the developed world common etiologies of CP are:
Idiopathic
Post-surgical
Radiation injury
___ was very common before the advent of effective therapy and remains important as a cause of CP in developing countries.
TB
In “pure” constriction, ventricular contractile function is _____, although ejection fraction (EF) can be reduced due to a small end-diastolic volume
Preserved
This sign reflects loss of the normal increase in right heart venous return on inspiration, even though tricuspid flow increases.
Kussmaul sign
The most notable cardiac physical finding in CP is the _____, an early diastolic sound best heard at the left sternal border and/or cardiac apex
Pericardial knock
This sign in CP occurs slightly earlier and has a higher frequency content than a third heart sound and corresponds to early, abrupt cessation of ventricular filling.
Pericardial knock
_____ is seen in a minority of patients with CP and suggests TB but is not diagnostic of constrictive physiology.
Pericardial calcification
Major 2D echo findings in CP include:
(1) pericardial thickening and calcification (best appreciated with TEE)
(2) abrupt displacement of the interventricular septum during early diastole (septal “bounce”)
(3) systemic venous congestion (dilated hepatic veins, inferior vena caval distention with blunted respiratory variation)
Typically, patients with CP demonstrate a ≥ __% increase in mitral E velocity during expiration versus inspiration and increased diastolic flow reversal with expiration in the hepatic veins. Mitral E wave deceleration time is usually less than ____ milliseconds.
Mitral E velocity: ≥ 25%
Mitral E wave DT: < 160 ms
Tissue Doppler reveals increased e′ velocity of the medial mitral annulus and septal abnormalities corresponding to the “bounce.” Lateral mitral annular e’ is lower than medial annular e′, termed _____.
Annulus reversus
In CP, regional variations in deformation and strain include reduced LV circumferential strain, torsion, and early diastolic untwisting, with _____ longitudinal strain.
Preserved
In contrast, in restriction, circumferential strain and untwisting are preserved but _____ in the longitudinal direction.
Reduced
Regional longitudinal strain ratios of lateral LV wall/septum and RV free wall/septum indicative of pericardial-myocardial tethering are useful in differentiating constriction from constriction and improve after pericardiectomy known as _____
Strain reversus
In CP, RA, RV diastolic, pulmonary capillary wedge, and pre-a wave LV diastolic pressures are elevated and equal, or nearly so, at around _____ mm Hg
20-25 mm Hg
In CP , the RA pressure tracing shows a _____. RV and LV pressures reveal an early, marked diastolic dip and plateau (“square root” sign)
Preserved x descent
Prominent y descent
Roughly equal a and v wave heights, with resultant M or W configuration
This the ratio of RV to LV systolic pressure × time on inspiration versus expiration
Systolic area index
A ratio greater than _____ strongly suggests constriction.
1.1
A ratio of RA pressure/ PCWP greater than ____ is an indicator of pericardial constraint that may distinguish pure constriction from constriction with myocardial involvement.
0.77
This is the most accurate method for measuring thickness (normal <2 mm)
ECG synchronized CT and EMR
The “normal” pericardium visualized by CMR is up to _____ mm in thickness.This most likely reflects the entire pericardial “complex,” with physiologic fluid representing a component of measured thickness.
CMR: 3-4 mm
In patients suspected of CP, _____ on T2 STIR and _____ on CMR is more specific for active inflammation and may be useful in identifying patients who are candidates for management with antiinflammatory drugs
T2 STIR: Periardial edema
CMR: LGE
In restriction, pulmonary venous systolic flow is _____ and diastolic flow is ______; this is not observed in constriction.
PV systolic flow: Blunted
PV diastolic flow: increased
Enhanced respiratory variation in mitral inflow velocity (>__%) is seen in constriction but varies by less than 10% in restriction
Constriction: > 25%
Restriction: < 10%
Recently proposed criteria (_____) distinguish constriction from restriction with sensitivity of 87% and specificity of 91%
(1) Respirophasic ventricular shift
(2) Preserved or increased medial mitral annulus e′ velocity [>9 cm/sec]
(3) Increased hepatic vein expiratory diastolic flow ratio [≥0.79]
Brain natriuretic peptide (BNP) levels are _____ in restrictive cardiomyopathy but usually ____ in constriction.
Restrictive CMP: Elevated
Constrictive pericarditis: Normal
In restriction, LV diastolic pressure is usually _____ than RV by at least 3 to 5 mm Hg, whereas in constriction LV and RV diastolic pressures _____ by more than 3 to 5 mm Hg.
LV diastolic pressures
Restriction: Higher than RV
Constriction:track closely and rarely differ
The absolute level of atrial or ventricular diastolic pressure is also useful, with extremely high pressures (>___ mm Hg) more common in restriction
> 25 mm Hg
Finally, the systolic area index is _____ in constriction than restriction and reported to have high sensitivity and specificity for distinguishing between them.
Greater
CP has a progressive but variable course. _____ is the definitive treatment in most patients.
Radical surgical pericardiectomy
Risk factors for poor results regarding pericardiectomy in CP include:
Radiation-induced disease
COPD
Renal insufficiency
Coronary artery disease and prior cardiac surgery
Reduced LV EF
Cardiopulmonary bypass
NYHA stage IV symptoms
Because sinus tachycardia is compensatory in CP, drugs that slow the heart rate should be avoided. In patients with atrial fibrillation and a rapid ventricular response, _____ is recommended for rate control.
Digoxin
A more aggressive approach of pericardiectomy in CP, with _____ of the pericardium has been advocated to facilitate access to the lateral, diaphragmatic, and posterior surfaces of the heart.
Complete removal
_______ is an adjunct to conventional débridement or as the sole technique in patients with extensive, calcified adhesions.
Ultrasonic or laser débridement
The ______ procedure in which multiple transverse and longitudinal incisions are made in the epicardial layer, is an alternative in patients with extensive epicardial involvement and can be done without cardiopulmonary bypass.
Waffle procedure
Long-term results after pericardiectomy in CP are worst in patients with:
Radiation-induced disease
Impaired renal function
Reduced LV EF
Moderate or severe tricuspid regurgitation
Low serum sodium
Advanced age
Poor responses to pericardiectomy have been attributed to:
(1) Myocardial atrophy or fibrosis
(2) Incomplete resection
(3) Development of recurrent cardiac compression by mediastinal inflammation and fibrosis
Reversible constriction typically resolves in _____ months or longer.
3-6 months
Intensity of enhancement as well as pericardial thickness ____ mm on late enhancement images is predictive of a response to antiinflammatory drugs with resolution of constriction
≥3 mm
A proposed definition of underlying constriction in ECP is _____.
Failure of RA pressure to decline by at least 50% to a level below 10 mm Hg when pericardial pressure is reduced to almost 0 mm Hg by pericardiocentesis and/or all detectable fluid is removed
The most common causes of ECP are:
Idiopathic
Malignancy
Radiation
Post-pericardiotomy
Connective tissue diseases
In ECP, _____ can be useful to identify patients with active inflammation who are more likely to respond to an antiinflammatory regimen
CMR with gadolinium uptake and measurement of hsCRP
_____ pericarditis is presumed to be the most common infection in countries with low TB prevalence
Viral
In sub-Saharan Africa the most common bacterial cause of pericardial disease is _____.
TB
A definitive diagnosis of TB pericarditis is based on _____.
Detection of tubercle bacilli in pericardial fluid or tissue
A probable diagnosis of TB pericarditis is based on _____.
Evidence of disease elsewhere
and/or
Lymphocytic pericardial exudate with elevated IFN-γ, ADA or lysozyme levels.
A presumptive diagnosis of TB pericarditis without evidence as outlined above is appropriate only in countries with high TB prevalence, followed by a _____.
Positive response to therapy
______ should be avoided in HIV patients with TB pericarditis because they may increase HIV- associated malignancies
Corticosteroids
Pericardiectomy is recommended in patients with TB pericarditis if the patient’s condition is not improving or is deteriorating after _____ weeks of therapy, and in appropriately selected patients with more long-standing constriction.
4-8 weeks
______ are among the organisms implicated in Fungal pericarditis
Aspergillus and Candida spp
HAART has reduced all forms of cardiac involvement except for _______ which are now the most common cardiac diseases in patients with HIV
Hypertensive Heart Disease and CAD
_____remains the most common cause of larger effusions in African HIV-infected patients
TB
There are three main presentations of pericardial disease in ESRD:
(1) Uremic pericarditis, often with moderate to large effusions, occurs before dialysis is initiated or within 8 weeks of initiation and is thought to be related to toxic metabolites
(2) “Dialysis” pericarditis, occurring more than 8 weeks after dialysis initiation
(3) CP, rarely
_____ is effective in uremic pericarditis
Intensive dialysis
In patients already receiving dialysis, ______ is less effective but remains a mainstay of treatment.
Intensification
Current guidelines for the treatment of pericarditis in ESRD recommend NSAIDs, specifically _____ as first-line therapy.
1 to 2 weeks of:
(1) Aspirin (750 to 1000 mg every 8 hours)
or
(2) Indomethacin (600 mg every 8 hours)
CP in autoimmune disease is rare, but most common in ____.
RA
The most common auto-inflammatory periodic fevers are:
Familial Mediterranean fever (FMF)
TNF receptor-associated periodic syndrome
Post-cardiac injury syndromes (PCISs) include:
Post-MI pericarditis
Post-pericardiotomy syndrome (PPS)
Posttraumatic pericarditis
With the exception of _____ pericarditis, all are presumed to have an immune pathogenesis triggered by damage to pericardial tissue and/or blood in the pericardial sac associated with myocardial necrosis (late post-MI pericarditis), surgical trauma (PPS), or iatrogenic trauma (pericarditis after percutaneous procedures including coronary intervention [PCI], valve repair, arrhythmia ablation, device implantations, and left atrial isolation).
EARLY post-MI pericarditis
According to proposed criteria diagnosis of PCIS (Post Cardiac Injury Syndrome) after cardiac injury requires at least two of the following:
(1) fever without an alternative cause
(2) pleuritic chest pain
(3) pericardial/pleural rubs
(4) pericardial effusion
(5) elevated CRP
Early post-MI pericarditis occurs _____ days after MI. It is rare in the primary PCI era and is now seen after large, transmural MIs due to absent or late/failed reperfusion.
1-3 days
Late post-MI pericarditis (_____ syndrome) is also rare (<1% of MIs in the modern era) and also most common after large MIs.
Dressler Syndrome
Because of its association with large MIs, early post-MI pericarditis should alert the clinician to possible _____, especially if an effusion is present
Rupture
ECG finding which appears to be sensitive for early post-MI pericarditis
Atypical T wave evolution (persistent upright T waves or early normalization of inverted T waves)
Late post-MI pericarditis occurs from _____ after MI.
1 week to a few months
Most pericardial involvement in cancer occurs in the setting of _____ disease, and may present as acute pericarditis, isolated effusion, ECP, or CP
Metastatic disease
Malignant effusions are often moderate to large and frequently cause tamponade. They are usually caused by direct pericardial implants resulting from ______ and less commonly by lymphatic involvement.
Hematogenous spread
Most common cancers that cause pericardial disease
Lung and breast carcinomas
The diagnosis of metastatic pericardial disease is based on confirmation of malignant infiltration of the pericardium by _____.
Pericardial fluid cytology or biopsy
General principles in the management of pericardial disease due to malignancy
- Appropriate antineoplastic therapy.
- Therapeutic and diagnostic pericardiocentesis for tamponade and as
a diagnostic tool for moderate to large, suspicious effusions. Pro-longed drainage is recommended to reduce the high recurrence rate (>40% to 50%). Additional interventions for recurrent effusions include surgical pericardial window and percutaneous balloon pericardiotomy. - Intrapericardial instillation of cytostatic/sclerosing agents is sometimes effective in preventing recurrences. The agent should be tailored to the type of cancer.
- Radiation for controlling effusions in patients with radiosensitive cancers such as lymphomas and leukemias. Management is often palliative in patients with advanced disease and aimed at symptom relief rather than aggressive treatment of the underlying cancer.
Various adverse cardiovascular effects have been ascribed to kinase targeted drugs.99 The main offender is _____, used to treat leukemias.
Dasatinib
Pericarditis occurring as an adverse response to cancer treatment is treated with _____ and otherwise similarly to idiopathic pericarditis, that is, NSAIDs and colchicine, with corticosteroids used in poorly responsive patients.
Discontinuation of the offending agent
Pericardial effusions develop in _____% of patients with severe hypothyroidism
25-35%
In the treatment of pericarditis during pregnancy, NSAIDs may be prescribed during the _____ trimester.
First and early second trimester
After gestational week 20, all NSAIDs (except _____) can cause constriction of the ductus arteriosus and should either not be started or withdrawn.
Aspirin ≤100 mg/day)
Pericardial cysts are rare, benign congenital malformations, typically located at the _____.
Right or left cardiophrenic angle
On CT imaging, cysts appear as round or elliptical masses with the same density as _____
Water
Surgery is not ordinarily recommended for pericardial cysts unless _____
Symptomatic
Congenital absence of the pericardium is very rare. Usually part or all of the ______ pericardium is absent.
Left parietal pericardium
Partial absence of left pericardium is associated with:
ASD
BAV
Pulmonary malformations
In patients with congenital absence of the pericardium (usually partial absence of the left pericardium), the ECG typically reveals:
ICRBBB
Absence of all or most of the left pericardium results in a chest radiograph with a _____ shift of the cardiac silhouette and an _____ left heart border.
Leftward shift
Elongated
Echocardiography in congenital absence of the pericardium reveals:
Paradoxical septal motion
RV enlargement
_____ ameliorates symptoms and prevents herniation in patients with congenital absence of the pericardium
Pericardiectomy
Lethal primary pericardial tumors
Mesothelioma
Fibrosarcoma
