B4-062 Pericarditis and B4-070 Uremic Pericarditis Flashcards
common presentation of pericarditis
sharp pain aggravated by inspiration
relieved by sitting up and leaning forward
friction rub
acute pericarditis may be preceeded by a […] phase
prodromal
fever, malaise, fatigue, dyspnea
tachycardia in pericarditis is due to
pain or fever
velcro sound
leather rubbing
high pitched
pericardial rub
what would you expect to see on ECG?
tachycardia
ST elevation
current of injury
low voltage=large effusion
following acute pericarditis [ECG finding] may persist for weeks to months
T wave inversion
the ST elevation in pericarditis is described as
concave
typical electrocardiogram findings
small to trace effusion
diagnostic criterion
- chest pain
- pericardial rub
- ECG changes
- some effusion
must have 2/4
most common causes of pericarditis
- idiopathic
- iatrogenic
- trauma
major predictors of severity
- fever
- subacute onset
- cardiac tamponade
- large effusion
- NSAIDS ineffective after 7 days
if the patient does not have major risk factors, should they be admitted or treated as outpatient?
outpatient
NSAIDs should be taken for
4-6 weeks
second line treatment for refractory or rheumatologic etiology
corticosteroids
not first line
first line treatment
- high dose NSAIDs
- cholchicine
top reasons why pericarditis would recur
- non adherent to bedrest
- tapered NSAIDs too quickly
DOC inflammatory recurrent pericarditis
anti IL-1 agents
DOC non-inflammatory recurrent pericarditis
azathioprine, IV Ig
trial drug resulting in rapid resolution of recurrent pericarditis
rilonacept
complications of acute pericarditis
- cardiac tamponade
- constrictive pericarditis
most common cause of pericarditis
idiopathic
immunocompromised state indicates
more severe disease
pain lasts for days, is knifelike, and intense
acute pericarditis
scratchy superficial velcro rub or leathery rub on ausculatation
acute pericarditis
upward concave ST elevation with PR segment elevation
acute pericarditis
diminshed QRS complexes
cardiac tamponade
most patients with acute pericarditis have […] effusion
trace
loculated pericardial effusion is most often seen in
recurrent pericarditis
first line treatment for acute uncomplicated pericarditis
ibuprofen 600 mg for 6 weeks
aspirin 650 mg for 6 weeks
high risk criteria for acute pericarditis
6
- troponin elevation
- large effusion
- high fever
- immunocompromised state
- subacute course
- poor response to NSAIDs
resolution of ECG changes in acute pericarditis
- ST elevations resolve/normalize
- intially upright T waves flatten and become inverted. may remain inverted for long period of time or indefinitely
for patients who have not responded to NSAIDs within the first few days, offer
colchicine
acts by concentrating in the neutrophils and prevents neutrophil migration
colchicine
last line therapy for acute pericarditis
prednisone
recurrent pericarditis is seen in […]% of cases
30
associated with high risk of recurrence
shorter duration of NSAIDs
rapid taper of NSAIDs
non compliance with bedrest
prednisone therapy is associated with a higher rate of
recurrence
recurrence is more likely in individuals who are
immunocompromised
large volume pericardiocentesis can help
establish diagnosis and rule out infectious etiology
most patients with uremic pericardial effusion have […] effusion
exudative
transudative effusion in uremic pericarditis may be associated with
2
- malnourishment
- nephrotic syndrome with low albumin
effusion is:
* high in protein
* high LDL
* high mononuclear cell count
* low pH
* high specific gravity
uremic pericarditis
treatment reserved only for constrictive pericarditis
pericardial resection
reaccumulation of a large pericardial effusion due to a clogged or ineffective drain should be treated with
emergency ultrasound-guided pericardial tap with repositioning of the drain
if that doesnt work –> pericardial window
cardiac chamber that is first to compress
right atrium
next is RV in diastole
chambers that show the earliest signs of cardiac tamponade
- right atrium
- right ventricle
cardiac tamponade physiology
intra-pericardial pressure becomes higher than diastolic intracardiac pressures
causes decreased SV and CO
why does cardiac tamponade cause tachycardia?
SV is reduced, the only way to maintain CO is too increase heart rate
classic ECG findings of cardiac tamponade
- low QRS voltage
- electrical alternans
the amplitude of every other ECG complex is lower than the preceding one
electrical alternans
is caused by heart swinging from beat to beat in sac of water
electrical alternans
greater than 10mmHg decrease in systolic pressure during inspiration
pulsus paradoxus
pulsus paradoxus
as RV increases in volume, LV is compressed causing
- decreased LV stroke volume
- decreases in systolic blood pressure
best measured by careful and slow auscultation using a manual sphygmomanometer
pulsus paradoxus
pulsus paradoxus can be diagnosed via palpation of
radial pulses
pulses paradoxus is indicative of
cardiac tamponade
before any drain is removed, what should be done to confirm there is no more pericardial fluid left?
repeat echocardiogram
pericardial knock is associated with
constrictive pericarditis
slightly high pitched sound hear in early diastole caused by the abrupt cessation of diastolic filling
pericardial knock
as ventricle hits stiffened pericardium
Kussmaul’s sign
when patient breathes in JVP goes up from the mid neck level to the level of the mandible
positive Kussmaul’s sign
constrictive pericarditis
increasing venous return fails to be accomodated in the heart causing increased JVP on respiration
Kussmaul’s sign
constrictive pericarditis
if draining one chamber does not result in much resolution of effusion,
multiple localations
consider pericardial window
what imaging can detect pericardial inflammation
ganolinium contrast enhanced cardiac MRI
chylous pericardial effusion is caused by
disruption of thoracic duct
lymph is rich in […], giving its milky appearance
TGs
both constrictive pericarditis and cardiac tamponade result in decreases
cardic output
which etiology of constriction is associated with the worst prognosis following pericardial resection
radiation
activity guidelines following pericarditis
strict bedrest for a few days followed by gradual resumption of activity
normally, intra-pericadial pressue should be […] intra-cardiac pressure
less than or equal to
facilitates venticular filling
most common cause of acute pericarditis in the general population
idiopathic
superficial scratchy sound
pericardial rub
acute pericarditis
acts by tubulin disruption and inhibiting microtubule polymerization
colchicine
failure of JVP to decrease on inspiration
Kussmaul’s sign
constrictive pericarditis
most effective treatment for uremia pericarditis with moderate effusion
dialysis
gold standard imaging modality for cardiac tamponade
echocardiography
worldwide, the leading cause of constricitive pericarditis is
tuberculosis
in the US, the leading cause of restrictive pericarditis is
trauma or post surgery
given in refractory cases that have failed NSAIDs and colchicine
prednisone
if patient continues to have discomfort after NSAIDs, start
colchicine
most patients with acute pericarditis have […] effusion
trace
most cases of acute pericarditis are
idiopathic
most likely ECG finding in a patient with uneventful recovery from acute pericarditis
normalization of ST elevation with subtle T wave inversions
[…] indicates a more severe acute pericarditis is likely
immunocompromised
acute pericarditis can develop large effusions, resulting in
cardiac tamponade
cardiogenic shock may be caused by
cardiac tamponade
