Cardiology #13 (Pericardial Effusion, Tamponade, Pericarditis, Ortho Hypo)

Question 1

What is a pericardial effusion?

Answer 1

accumulation of fluid in the pericardial space

Question 2

Etiologies of pericardial effusion

Answer 2

-Idiopathic
-Viral
-Malignancy (lung cancer MC)

Question 3

Symptoms of a pericardial effusion

Answer 3

-Chest pain
-Dyspnea
-Fatigue
-Decreased/Muffled heart sounds (due to fluid)

Question 4

Diagnostic of choice for a pericardial effusion

Answer 4

Echocardiogram

Question 5

What is seen on an ECG with a pericardial effusion?

Answer 5

-Electrical alternans (alternating amplitudes of QRS complexes)
-Low QRS voltage

Question 6

Although a chest radiograph is normally NOT used in the diagnosis of pericardial effusion, what may be seen on the CXR?

Answer 6

Water bottle heart

Question 7

Treatment for pericardial effusion

Answer 7

-Treat underlying cause
-Serial echocardiography if necessary
-Large effusions may need pericardiocentesis for symptomatic relief

Question 8

What is a cardiac tamponade?

Answer 8

Pericardial effusion causing significant pressure on the heart, impeding cardiac filling, leading to decrease cardiac output and shock (medical emergency)

Question 9

MC nontraumatic cause of cardiac tamponade

Answer 9

Malignancy

Question 10

Symptoms of a cardiac tamponade

Answer 10

Beck’s Triad: muffled heart sounds, increased JVP, systemic hypotension
Pulsus Paradoxus: exaggerated (>10 mmHg) decrease in systolic BP with inspiration
Dyspnea, fatigue, peripheral edema, shock, tachycardia, cool extremities

Question 11

What is seen on echocardiogram in a cardiac tamponade?

Answer 11

Pericardial effusion + diastolic collapse of cardiac chambers

Question 12

Much like a pericardial effusion, what is seen on ECG with a cardiac tamponade?

Answer 12

Electrical alternans (low voltage QRS, alternating high and low QRS)

Question 13

Definitive diagnostic for cardiac tamponade

Answer 13

Right heart catheterization

Question 14

Treatment for cardiac tamponade

Answer 14

Immediate pericardiocentesis to remove the pressure
Volume resuscitation and pressor support if needed.

Question 15

What treatment should be pursued for cardiac tamponade if the condition is recurrent?

Answer 15

Pericardial window

Question 16

What is constrictive pericarditis?

Answer 16

Loss of pericardial elasticity (thickening, fibrosis, and calcification) leading to restriction of ventricular diastolic filling

Decreases stroke volume and cardiac output

Question 17

In the US, _____ and ____ are the most common causes of constrictive pericarditis. Worldwide, ______ is the MCC

Answer 17

Idiopathic and viral illness

Tuberculosis

Question 18

Symptoms of constrictive pericarditis

Answer 18

-Dyspnea (MC), Orthopnea, fatigue
-Right sided HF symptoms: Increased JVD, peripheral edema, nausea, vomiting, Kussmaul’s Sign (lack of inspiratory decline or increased in JVP with inspiration)
-Pericardial knock: high pitched diastolic sound similar to S3

Question 19

What is seen on echocardiogram for constrictive pericarditis?

Answer 19

Pericardial thickening and/or calcification
Square root sign: early diastolic dip followed by a plateau of diastasis

Question 20

What is a diagnostic that is MORE sensitive than an echocardiogram for constrictive pericarditis?

Answer 20

MRI or CT scan

Question 21

Medical management for constrictive pericarditis

Answer 21

Diuretics for symptom relief as well as reduction of edema and pressure

Question 22

What is the definitive treatment for constrictive pericarditis?

Answer 22

Pericardiectomy

Question 23

What is postural (orthostatic) hypotension?

Answer 23

Hypotension within 2-5 minutes of standing (or 5 minutes of supine rest) defined by a least 20 mmHg fall in systolic pressure and/or at least 10 mmHg fall in diastolic pressure

Question 24

Name 5 causes of orthostatic hypotension

Answer 24

-Impaired autonomic function
-Meds: Antihypertensives, Diuretics, Narcotics, Antidepressants
-EtOH
-Diabetic neuropathy
-Parkinson’s Disease
-Hypovolemia (Loop Diuretics, vomiting, hemorrhage)

Question 25

Symptoms of orthostatic hypotension due to cerebral hypoperfusion

Answer 25

Dizziness, fatigue, lightheadedness, palpitations, blurry vision, syncope

Question 26

What is included in the workup of a patient with orthostatic hypotension?

Answer 26

Blood pressure management
Tilt Table Test: blood pressure reduction at 60-degree angle
Labs (Electrolytes, BUN, creatinine, glucose) to evaluate for anemia or dehydration

Question 27

Initial therapy and management for postural (orthostatic) hypotension

Answer 27

Conservative: increasing salt and fluid intake, gradual position changes, compression stockings, exercise, caffeine, discontinue offending medications

Question 28

What is the first-line medical management of orthostatic hypotension?

Answer 28

Fludricortisone

Question 29

If additional medical therapy is necessary, or if the patient cannot take Fludricortisone, what other two options for medications are out there?

Answer 29

Midodrine
Droxidopa

Question 30

What are some other recommendations you can give to patients with orthostatic hypotension?

Answer 30

Avoid the flat position
Sleep with the head of the bed raised 30-45 degrees