B4.062 Big Case Pericarditis Flashcards
list the layers of the pericardium
fibrous pericardium (outermost) parietal layer of serous pericardium pericardial fluid visceral layer of serous pericardium (innermost) myocardium
what structures attach to the fibrous pericardium to keep the heart in place
aorta
pulm artery and veins
IVC and SVC
how much pericardial fluid is normal
20-33 ccs
normal pericardial functions
attaches the heart to the thorax (prevents it from moving)
protective covering (shock absorber)
lubricant to decrease friction with heart beats
prevents excessive dilatation in situations of volume excess
helps with diastolic relaxation of the cardiac muscle
typical time span of MI or angina
30 min- 6 hours max
what are some identifying characteristics of GERD as a source of chest pain
association with food
worse when laying flat
symptoms of aortic dissection
severe chest, neck, or back pain can be ripping/tearing, but commonly sharp abrupt and maximal in onset nausea, vomiting, diaphoresis syncope (5-10%)
characterize the pain associated with pericarditis
mid sternal chest pain sharp/ knife like worse with deep inspiration/ cough better when sitting worse with laying supine unrelenting (longer lasting than MI or angina)
symptoms of acute pericarditis
pain prodromal phase fever malaise several days to weeks dyspnea fatigue
physical exam findings associated with acute pericarditis
tachycardia
increased temp
pericardial rub
discuss how to hear a pericardial rub
press stethoscope diaphragm firmly to the chest wall
may be exacerbated by deep inspiration
best heard when patient is sitting and leaning forward
what does a pericardial rub sound like
Velcro like
leather rubbing
scratchy/superficial
typical work up for acute pericarditis
blood work: troponins, CBC, ESR CXR: rule out pneumonia, rub fracture ECG echo other imaging: CT, MRI (usually not done)
ECG findings with acute pericarditis
tachycardia
diffuse concave upward ST elevations
PR depressions
low voltage if large effusion present
echo findings with acute pericarditis
cannot see inflamed pericardium
most have pericardial effusions (usually small, occasionally large)
what imaging can be used to visualize the inflamed pericardium
MRI with contrast
acute pericarditis diagnostic criterion
need 2 of 4 to diagnose
- characteristic chest pain
- pericardial friction rub
- classic ECG changes
- pericardial effusion
acute pericarditis supportive criterion
evidence of systemic inflammation
pericardial inflammation on MRI/CT
primary causes of acute pericarditis
idiopathic (85-90%) infectious neoplastic autoimmune MI
major predictors of pericarditis severity
fever > 100.4 subacute onset evidence suggestive of cardiac tamponade large pericardial effusion NSAIDs ineffective after 7 days
minor predictors of pericarditis severity
immunosuppressed state
history of oral anticoagulation therapy
acute trauma
elevated cardiac troponin (suggestive of myopericarditis)
mainstays of pericarditis treatment
restriction of physical activity for several weeks
NSAIDs
colchicine
discuss the dosing of NSAIDs in pericarditis treatment
high dose (600-800 mg 4x daily)
4-6 weeks
gradually taper to reduce risk of recurrence
take w food to prevent damage to gastric mucosa
when should you use corticosteroids for pericarditis
not first line
may increase risk of recurrence
NSAID intolerant patients
pericarditis secondary to rheumatologic disease
what is colchicine
not an NSAID
concentrated in neutrophils and prevents their migration by disrupting microtubule polymerization
decreases inflammation
takes a few days to start working
adverse effect of colchicine
diarrhea
classification of pericarditis based on duration
acute: a few weeks (4-6 weeks)
incessant/intractable: >6 weeks
chronic: >3-6 months
recurrent: resolves but comes back after 4-6 weeks
discuss the features of incessant pericarditis
may accumulate more fluid/tamponade
fluid may become exudative/organized
follow ups for acute pericarditis
assess clinical response after 1 week
see in 3-4 weeks to taper NSAIDs if things are going well
occurrence of recurrent pericarditis
15-30%
reasons for recurrent pericarditis
unknown
autoimmune process maybe
more often in immunocompromised
may relate to: inadequate treatment of initial inflammation, initial use of corticosteroids
management of recurrent pericarditis
look for etiology
exercise restriction
NSAID as prior
colchicine: weight based dose as high as tolerated, at least 6 months
management of really intractable cases of recurrent pericarditis
IV immunoglobulins
azothiaprine
anakinra
make sure no infection
last resort for pericarditis
surgical pericardiectomy
doesn’t always end recurrences bc some can be stuck to myocardium and remain
complications of acute pericarditis
cardiac tamponade
constrictive pericarditis
