B4.062 Big Case Pericarditis Flashcards

1
Q

list the layers of the pericardium

A
fibrous pericardium (outermost)
parietal layer of serous pericardium
pericardial fluid
visceral layer of serous pericardium (innermost)
myocardium
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2
Q

what structures attach to the fibrous pericardium to keep the heart in place

A

aorta
pulm artery and veins
IVC and SVC

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3
Q

how much pericardial fluid is normal

A

20-33 ccs

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4
Q

normal pericardial functions

A

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

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5
Q

typical time span of MI or angina

A

30 min- 6 hours max

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6
Q

what are some identifying characteristics of GERD as a source of chest pain

A

association with food

worse when laying flat

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7
Q

symptoms of aortic dissection

A
severe chest, neck, or back pain
can be ripping/tearing, but commonly sharp
abrupt and maximal in onset
nausea, vomiting, diaphoresis
syncope (5-10%)
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8
Q

characterize the pain associated with pericarditis

A
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)
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9
Q

symptoms of acute pericarditis

A
pain
prodromal phase
fever
malaise
several days to weeks
dyspnea
fatigue
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10
Q

physical exam findings associated with acute pericarditis

A

tachycardia
increased temp
pericardial rub

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11
Q

discuss how to hear a pericardial rub

A

press stethoscope diaphragm firmly to the chest wall
may be exacerbated by deep inspiration
best heard when patient is sitting and leaning forward

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12
Q

what does a pericardial rub sound like

A

Velcro like
leather rubbing
scratchy/superficial

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13
Q

typical work up for acute pericarditis

A
blood work: troponins, CBC, ESR
CXR: rule out pneumonia, rub fracture
ECG
echo
other imaging: CT, MRI (usually not done)
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14
Q

ECG findings with acute pericarditis

A

tachycardia
diffuse concave upward ST elevations
PR depressions
low voltage if large effusion present

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15
Q

echo findings with acute pericarditis

A

cannot see inflamed pericardium

most have pericardial effusions (usually small, occasionally large)

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16
Q

what imaging can be used to visualize the inflamed pericardium

A

MRI with contrast

17
Q

acute pericarditis diagnostic criterion

A

need 2 of 4 to diagnose

  1. characteristic chest pain
  2. pericardial friction rub
  3. classic ECG changes
  4. pericardial effusion
18
Q

acute pericarditis supportive criterion

A

evidence of systemic inflammation

pericardial inflammation on MRI/CT

19
Q

primary causes of acute pericarditis

A
idiopathic (85-90%)
infectious
neoplastic
autoimmune
MI
20
Q

major predictors of pericarditis severity

A
fever > 100.4
subacute onset
evidence suggestive of cardiac tamponade
large pericardial effusion
NSAIDs ineffective after 7 days
21
Q

minor predictors of pericarditis severity

A

immunosuppressed state
history of oral anticoagulation therapy
acute trauma
elevated cardiac troponin (suggestive of myopericarditis)

22
Q

mainstays of pericarditis treatment

A

restriction of physical activity for several weeks
NSAIDs
colchicine

23
Q

discuss the dosing of NSAIDs in pericarditis treatment

A

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

24
Q

when should you use corticosteroids for pericarditis

A

not first line
may increase risk of recurrence
NSAID intolerant patients
pericarditis secondary to rheumatologic disease

25
Q

what is colchicine

A

not an NSAID
concentrated in neutrophils and prevents their migration by disrupting microtubule polymerization
decreases inflammation
takes a few days to start working

26
Q

adverse effect of colchicine

A

diarrhea

27
Q

classification of pericarditis based on duration

A

acute: a few weeks (4-6 weeks)
incessant/intractable: >6 weeks
chronic: >3-6 months
recurrent: resolves but comes back after 4-6 weeks

28
Q

discuss the features of incessant pericarditis

A

may accumulate more fluid/tamponade

fluid may become exudative/organized

29
Q

follow ups for acute pericarditis

A

assess clinical response after 1 week

see in 3-4 weeks to taper NSAIDs if things are going well

30
Q

occurrence of recurrent pericarditis

A

15-30%

31
Q

reasons for recurrent pericarditis

A

unknown
autoimmune process maybe
more often in immunocompromised
may relate to: inadequate treatment of initial inflammation, initial use of corticosteroids

32
Q

management of recurrent pericarditis

A

look for etiology
exercise restriction
NSAID as prior
colchicine: weight based dose as high as tolerated, at least 6 months

33
Q

management of really intractable cases of recurrent pericarditis

A

IV immunoglobulins
azothiaprine
anakinra
make sure no infection

34
Q

last resort for pericarditis

A

surgical pericardiectomy

doesn’t always end recurrences bc some can be stuck to myocardium and remain

35
Q

complications of acute pericarditis

A

cardiac tamponade

constrictive pericarditis