Chapter 288 - Pericardial Disease Flashcards
Name the functions of the normal pericardium.
“The normal pericardium, by exerting a restraining force, prevents sudden dilation of the cardiac chambers, especially the right atrium and ventricle, during exercise and with hypervolemia. It also restricts the anatomic position of the heart, and probably retards the spread of infections from the lungs and pleural cavities to the heart.”
The partial absence of the pericardium might be related to sudden death.
True or False?
True.
“In partial left pericardial defects, the main pulmonary artery and left atrium may bulge through the defect; very rarely, herniation and subsequent strangulation of the left atrium may cause sudden death.”
The pain related to acute pericarditis has always pleuritic characteristics.
True or False?
False.
“The pain of acute pericarditis is often severe, retrosternal, and left precordial, and referred to the neck, arms, or left shoulder. Frequenetly the pain is pleuritic, consequent to accompanying pleural inflammation (…) but sometimes it is steady, constricting, radiates into either arm or both arms, and resembles that of myocardial ischemia”
Name five examples of pericarditis in which there might not be any chest pain.
“Pain is often absent in slowly developing tuberculous, postirradiation, and neoplastic, uremic, and constrictive pericarditis.”
Since acute pericarditis might be confounded with myocardial infarction and both might have elevation of serum biomarkers, how does one distinguish the pattern of elevation of these conditions?
“However, these elevations, if they occur, are quite modest given the extensive electrocardiographic ST-segment elevation in pericarditis. This dissociation is useful in differentiating between these conditions.”
How frequent does one hear a pericardial friction rub at some point of the acute pericarditis?
85%
What are the four principal diagnostic features of acute pericarditis?
Chest pain, pericardial friction rub, supra-ST on ECG and pericardial effusion.
The main ECG characteristic of acute pericarditis is the presence of widespread ST elevation. What leads might be recipocrally depressed?
aVR and sometimes V1
What is the pathophysiollogy of ST segment elevation and PR segment depression in acute pericarditis?
ST segment elevation is do due to envolvement of epicardial tissue whereas PR segment depression is due to atrial envolvement.
Explain the stages of ECG changes in acute pericarditis.
“In stage 1, there is widespread elevation of the ST segments (…) After several days, the ST segments return to normal (satage 2), and only then, or even later, do the T waves become inverted (stage 3). Weeks or months after the onset of acute pericarditis, the ECG returns to normal (stage 4).”
What are the main differences of an ECG due to acute pericarditis and acute myocardial infarction (AMI)?
” The electrocardiogram (ECG) in in acute pericarditis without massive effusion usually displays changes secondary to acute subepicardial inflammation (…) there is widespread elevation of the ST segments, often with upward concavity, involving two or three standard limb leads and V2 to V6, with reciprocal depressions only in aVR and sometimes V1.”
“In contrast, in AMI, ST elevations are convex, and reciprocal depression is usually more proeminent; these changes may return to normal within a day or two. Q waves may develop, with loss of R-wave amplitude, and T-wave inversions are usually seen within hours before the ST segments have become isoelectric.”
How do you define clinically a pericardial effusion? What is Ewart’s sign?
“Pericardial effusion is usually associated with pain and/or the ECG changes mentioned above, as well as electrical alternans. Pericardial effusion is especially important clinically when it develops within a relatively short of time because it may lead to tamponade (…) heart sounds may be fainter with pericardial effusion. The base of the left lung may be copmpressed by pericardial fluid, producing Ewart’s sign, a pacth of dullness and increased fremitus (and egophony) beneath the angle of the left scapula.”
In echocardiography where does one look for small pericardial effusions?
“The presence of pericardial fluid is recorded by two-dimensional transthoracic echocardiography as a relatively echo-free space between the posterior pericardium and left ventricular epicardium in patients with small effusions”
Compare CT and MRI to echocardiography.
CT and MRI “may be superior to echocardiography in detecting loculated pericardial effusions, pericardial thickening, and the identification of pericardial masses.”
Define Mulibrey nanism.
“An autosomal recessive syndrome characterized by growth failure, muscle hypotonia, hepatomegaly, ocular changes, enlarged cerebral ventricles, mental retardation, ventricular hypertrophy, and chronic constrictive pericarditis.”
Which therapies might be responsible for decreasing and increasing the risk for recurrent acute pericarditis?
Colchicine and glucocorticoids, respectively.
Which therapies and respective dosages are useful in acute pericarditis?
Aspirin (2-4g/d) with gastric protection (omeprazole 20mg/d) or NSAIDs such as ibuprofen (400-600mg tid) or indomethacin (25-50mg tid) for 1-2 weeks
Colchicine (0,5mg bid) for 4-8 weeks
Glucocorticoids (prednisone 1mg/Kg per day)
Which group of drugs should be avoided in acute pericarditis?
“Anticoagulants should be avoided because their use could cause bleeding into the pericardial cavity and tamponade.”
Which patients might be candidates for pericardial stripping?
“In patients with recurrences that are multiple, frequent, disabling, continue for more than 2 years, and are not prevent by colchicine and other NSAIDs and are not controlled by glucocorticoids, pericardial stripping may be necessary to terminate the illness, and usually does so.”
What are the main causes of cardiac tamponade?
“The most common causes of tamponade are idiopathic pericarditis and pericarditis secondary to neoplastic disease. Tamponade may also result from bleeding into the pericardial space after leakage from an aortic dissection, cardiac operations, trauma, and treatment of pacients with acute pericarditis with anticoagulants.”
What are the features of Beck’s triad.
“hypotension, soft or absent heart sounds, and jugular venous distension with a proeminent x descent but an absent y descent.”
Is there a cutoff volume that is responsible for cardiac tamponade?
No, the cardiac tamponade depends on the velocity at which the pericardial effusion develops. Therefore, “The quantity of fluid necessary to produce cardiac tamponade may be as small as 200 mL when the fluid develops rapiodly to as much as >2000mL in slowly developing effusions when the pericardium has had the opportunity to stretch and adapt to an increasing volume.”
