Block I: myocardial/pericardial disease Flashcards
most cases of myocarditis are []
infectious
-viral bacterial, rickettsial, spirochetal, fungal, parasitic
-
[] is the most common cause myocarditis
viral, exp. coxackie
how might myocarditis patients present?
with heart failure without any preceding symptom
pleural or pericardial chest pain, often sharp in nature
heart failure without preceding symptoms may indicate
myocarditis
when might myocarditis occur in patients?
several days to a few weeks after the onset of an acute febrile illness or respiratory tract infection (although can be longer)
PE exam reveals
- tachycardia
- gallop rhythm
- heart failure
- conduction defect
what do you suspect?
myocarditis
what might be revels on PE in a myocarditis pt.
- tachycardia
- gallop rhythm
- heart failure
- conduction defect
EKG in a myocarditis patient may reveal []
NOS ST-T changes and conduction disturbance
what may appear on a CXR of a myocarditis patient?
cardiomegaly, nos but likely present
[] provides the most convenient way of evaluating cardiac function
echo
-can be used to exclude other processes and view any dilation of ventricles
how are you treating a myocarditis patient?
- specific ABX when infecting agent ID
2. until agent det. treatment directed toward symptoms caused by heart failure and dysrhythmias
what is the prognosis of myocarditis
- most resolve spontaneously
2. others cardiac function deterioates progressively and may lead to dilated cardiomyopathy
dilated cardiomyopathy may represnt []
end stage viral myocarditis
why is rapid fluid expansion of 30 mL more detrimental than a slow fluid expansion of 1L (in terms if pericardial fluid)
pericardium cannot stretch rapidly, if fluid accumulates more quickly than it will affect hearts ability to pump
pericardium can stretch slowly over a period of time to acomodate slow increase in fluid
what is a major complication of rapid effusion of pericardium
tamponade
how much fluid is normally in the pericardium?
20-50mL
how much pericardial fluid can cause significant disturbances?
60 mL
(20-50mL) normally
[] results from inflammation of pericardium with subsequent accumulation of pericardial fluid (effusion)
acute pericarditis
what causes pericarditis?
- infectious
2. non- infectious (Ct disease, drug related, malignancy)
the cardinal symptom of pericarditis is []
chest pain
chest pain described as retrosternal, sharp, pleuritic pain is usually []
pericarditis
pain that frequently radiates to the left trapezius ridge, and is aggravated by swallowing, coughing, and lying flat is usually
pericarditis
pericardial pain may be alleviated by []
sitting upright and taking shallow breath
make sure its alleviated and not achieved
what is the most common cause pericarditis
viral
males under age 50 most commonly affected
pericardial involvement typically follows []
URI
how will you treat a pericarditis pt?
- sympotmatic
- ASA
- ibuprofen
- indomethiacin
- corticosteroids may be benificial in patients who do not respond to anti-inflammatory medication
[] anticoagulant is considered safe for pts. who need anticoagulation that may also need surgeyr
heparin
what patients should never be taken off of anticoagulants? even if surgery is sure?
patients with artificial valves
what is a major early complication of pericarditis
tamponade ( < 5%)
pericardial resection if indicated in []
constrictive pericarditis
once purulent pericarditis is dx, what is the next step?
- timely drainage of pericardial fluid & culture
2. Vanc + ceftriaxone or cefepime until culture comes back
pericarditis may occur 2-5 days after [] and is due to []
MI, transmural myocardial necrosis
[] may be heard in a post MI pericarditis pt.
rub
[] change on EKG of post MI pericarditis pt
replarization changes,
may be confused with ischemia
what can provide symptom releif to post MI pericarditis pt?
aspirin or NSAID
[] occurs 1-12 weeks post MI or open heart surgery and is believed to be an autoimmune d/o that presents with pain, fever, malaise, leukocytosis
dressler’s syndrome
rapid collection of [] mL in pericardial fluid can cause severe hemodynamic compromise
100-200
enlarged cardiac silhouette with globular configuration may suggest
effusion
[] are beat to beat changes in one or more portions of electrocardiogram and is pathognomonic in pericardial effusion
electrical alternans
[] is the primary method for demonstrating pericardial effusion
echocardiogram
[] discriminates effusion from heart failure
echocardiogram
[] is a possible precursor to tamponade
cardiac effusion
[] can lead to thickened, fibrotic, adherent pericardium that restricts diastolic filling and produced chronically elevates venous pressure
constrictive pericarditis
constrictive pericarditis most commonly occurs after []
- radiation
- cardiac surgery
- viral pericarditis
* histoplasmosis uncomoon
[] is a paradoxical increase in JVD and pressure during inspiration
Kussmaul’s sign
describe Kussmaul’s sign, when does this occur?
- paradoxical increase in JVD and pressure during inspiration
- occurs in constrictive pericarditis and restrictive cardiomyopathy
an echocardiogram demonstrating thick pericardium and small chamber indicates
constrictive pericarditis
how to treat constrictive pericarditis?
gentle diuresis and surgical removal of pericardium in symptomatic patients
what d/o req. gentle diuresis?
constrictive pericarditis
what is a rare but life threatening complication of pericardial effusion?
tamponade
elevates intrapericardilal pressure of > 15mmHG that restricts venous reurn and ventricular filling is []
tamponade
what is the characteristic of tamponde
elevated intrapericardial pressure of > 15 mmHG that restricts venous return and ventricular filling
stroke volume and pulse pressure [] in tamponade
fall
heart rate and venous pressure [] in tamponade
rise
why might venous pressure rise in tamponade?
heart gets backs up in providing systemic circulatoin, veins cant deliver to backed up uheart
- tachycardia
- tachypnea
- narrow pulse pressure
- preseved systolic P
characteristics of []
tamponade
what is beck’s triad?
- distended jugular veins
- muffled heart tones
- hypotension with narrowing pulse pressure
*indicative of tamponade
what is pulse pressure?
Systolic P - diastolic P =pulse pressure
small diff of the two may indicate tamponade
what is > 10 mmHG decline in systolic P during inspiration as compared to expiration
pulses paradoxicus
what is pulsis paradoxicus and what might it reveal
> 10 mmHG decline in systolic pressure during inspiration as compared to expiration
result of further impairment of ventricular fluid
may lead to tamponade dx,
puslses paradoxicus is a classic finding in []
tamponade
hemodynamic deterioation during tamponade requires emergent []
drainage of pericardial fluid (pericardiocentesis) or throracic surgery (pericardial window)
temporizing measures can be used to treat tamponade by []
increased pre-load, i.e. amount of blood pouring into ventricle
what are some temporizing agents that can be used in tamponade?
inotropic agents dopamine, NE, Epi
to expand volume
what is a scratchy, triphasic, best heard along left sternal border during expiration when pt leands forward
rub
when is a rub best heard?
- when patient leads forward and holds expiration
best heard over L sternal border
what is a fundamental sign of pericarditis
pericardial friction rub
distant/mufled heart sounds suggest []
pericardial effusion
a chest x ray is usually [] in acute pericarditis
normal
water bottle shaped heart on xray indicates []
chronic pericarditis, effusion of > 200 mL
what are EKG changes assoc. with acute pericarditis
- diffuse ST segment elevation with
- upward concavity
- absence of recpircoal ST seg depression
in ALL LEADS
pericarditis may have depression [] in EKG
PR interval
low voltage QRS or electrical alternans may occur in []
effusion
pericarditis may show ST elevation in [] leads
all
MI may show elevation in [] leads
two
