Clinical Pericardial Disease Flashcards
How does the intrapericardial pressure vary with respiration?
-5 mmHg with inspiration
+5 mmHg with expiration
What is the function of the pericardium, and is it critical?
Limits the acute distension of the heart, lubricates and anchors the heart, and prevents the spread of infection to the heart.
However, it has no major vital function and can be removed
What do the visceral and parietal pericardium rub against when inflamed? What can happen to these layers if chronically inflamed?
Visceral - the heart
Parietal - innervated, against the pleura
Chronic inflammation -> thickening and tightening, restricting cardiac filling
What are the clinical symptoms of acute pericarditis?
Sharp or rubbing chest pain which is pleuritic, meaning it varies with intensity of chest wall movement or position such as sitting or lying down
Can mimic MI: Fever, tachycardia, dyspnea
Will hear a three part friction rub
What is the first stage of ECG changes with acute pericarditis? Include PR, QRS, and ST changes.
PR - often early PR segment depression from atrial involvement
QRS - low amplitude due to decreased ability to contract from pericardial effusion
ST - ST elevation in almost all leads, except aVR. Would normally indicate infarct in all coronary arteries, but super unlikely. No reciprocal changes on any lead.
How does the ECG recover overtime from acute pericarditis?
J point will come down, T waves will decrease in amplitude, invert, then finally resolve
What will happen to WBC count, ESR, and cardiac enzymes in pericarditis? What should you think if the third is elevated w/o other signs of pericarditis
WBC count - Mild lymphocytosis (inflammation state)
ESR - will be increased (+APP), due to fibrinogen helping form Rouleaux stacks with WBC
Cardiac enzymes - Increased
If cardiac enzymes are elevated w/o pericarditis, think myocarditis or silent MI with subsequent pericarditis
What are the viral causes of pericarditis? Especially in AIDS? How do you treat?
Coxsackievirus, adenovirus, echovirus
AIDS - CMV
These are usually self limiting
What causes the majority of pericarditis?
Idiopathic
What are the possible complications of viral pericarditis?
Myocarditis is biggest worry -> can lead to heart failure
Also may recur, cause tamponade, or constrict
What is the most common cause of bacterial pericarditis today, and what organisms?
Seen post-operatively, often in conjunction with endocarditis and bacteremia
Common organisms: S. pneumoniae (if from pneumonia as in past), S. aureus, other streptococci
What is the most essential treatment for bacterial pericarditis?
Early surgical drainage via pericardiocentesis
What is Tuberculous pericarditis? Describe it.
Pericarditis caused by TB, spread from chest & lymph nodes causing a blood effusion
Who is most liable to getting tuberculous pericarditis? What does it progress to?
Most common in AIDS population, often progresses to constriction with calcification.
What immune-mediated connective tissue diseases can cause pericarditis?
- Systemic lupus erythematosus
- Rheumatoid arthritis
- Scleroderma (Systemic sclerosis)
- Mixed connective tissue disease
What arteritis’s can cause pericarditis?
Polyarteritis nodosa, and temporal arteritis
What is the pathophysiology of Dressler’s syndrome? What does it result in and how is it treated?
Typically weeks or months post MI, can cause pericardial / pleural effusions due to sensitization of immune system to myocardial cells during necrosis.
Often causes constriction. Usually self-limited, but may need NSAIDs or steroids
What causes uremic pericarditis, and what is its typical progression? How is it treated?
Due to renal failure with accumulation of urea
Typically leads to slowly-accumulation pericardial effusion which can be accommodation, but may sometimes progress rapidly to tamponade
Treated via aggressive hemodialysis to filter urea
What is malignant pericarditis and its most common causes?
Pericarditis caused by tumor or fluid from tumor, which can cause tamponade
Often causes by lung carcinoma, breast carcinoma, lymphoma (also sometimes melanoma)
What is a common treatment for malignant pericarditis if it is very end-stage?
Surgically connect pericardial and pleural spaces for a “window” of drainage
How is radiation-induced pericarditis difficult to treat?
Happens following radiation cancer treatment, difficult to treat because it leads to fibrotic change -> constriction, restriction, drainage of fluid may not relieve symptoms
What drugs are commonly associated with pericarditis?
- Minoxidil - HF vasodilation
- Hydralazine (lupus-induced)
- Izoniazid
- Cyclosporine
What thyroid cause can lead to pericarditis? How does device-related pericarditis happen?
Thyroid - hypothyroidism
Device-related - Pacemakers can perforate
What are the congenital causes of pericarditis? What will these cause?
- Pericardial cyst - usually benign
- Congenital absence of pericardium -> risk of herniation of heart and sudden cardiac death, and possible coronary artery compression
How does congenital absence of the pericardium appear on X-ray?
“Snoopy dog” cardiac silhouette with marked lack of definition of left heart border
What is the general treatment for acute pericarditis?
2 weeks of NSAIDs for symptoms: Indomethacin or ibuprofen
Systemic steroids - if slow response
Colchicine - as an alternative to corticosteroids
How should you treat recurrent pericarditis? Medically / surgically?
Avoid steroids. Start with NSAIDs again, but lean more on colchicine which has fewer side effects.
May indicate surgical treatment via pericardiectomy
When is a pericardial effusion considered large? How does this look on X-ray?
When fluid is >2cm on echo.
X-ray = cardiac silhouette will appear rounded and flask-like
What happens to heart sounds and ECG in a very large pericardial effusion?
Heart sounds - reduced intensity of friction rub
ECG - electrical alternans -> cyclically varying size of R waves as heart swings back and forth in fluid-filled pericardial cavity
What is Ewart’s sign and why does it happen?
Dullness and decreased breath sounds with egophony (E sounds like an A) over posterior left lung
-> due to compression via large pericardial sac
What are the clinical signs of pericardial tamponade? What causes this?
Elevated venous pressure - JVD, hepatomegaly, edema
Reflex tachycardia due to hypotension and cardiogenic shock
-> impaired diastolic filling as intrapericardial pressure exceeds ventricular diastolic pressure
Muffled heart sounds
What happens to the pulse in pericardial tamponade? Why?
Pulsus paradoxus - defined as >10 mmHg drop in blood pressure in systolic BP during inspiration
Due to greatly increased venous return to RV in inspiration, RV pushes septum into LV which is diastolically constricted as is -> causes a massive drop in preload and increase in afterload, dropping stroke volume and systolic BP
Does pulsus paradoxus happen in constrictive pericarditis? Why or why not?
No -> in constrictive pericarditis, the RV also struggles to fill in diastole, so the septae does not deviate and there is not a >10 mmHg drop in BP
What are the features of tamponade on echo?
RA and RV diastolic collapse -> lowest pressure chambers, will collapse in early diastole before filling pressures bring it above pericardial sac
IVC “plethora” - very distended
What are the treatments for tamponade?
- Pericardiocentesis
2. Surgical - fluid removal + biopsy to determine cause, or pericardiectomy
What is the pathophys of constrictive pericarditis?
Fibrous thickening with adhesion to myocardium and calcification (concrete box for heart)
-> limits diastolic volume, looking like right-sided heart failure (elevated JVP, hepatomegaly, ascites, edema)
What are the most common causes of constrictive pericarditis?
post-cardiac surgery, healing w/fibrosis
TB / infection
Irradiation
Foreign body (i.e. defibrillator pathces)
Uremia - as in CKD
Sarcoidosis
What is Kussmaul’s sign? What causes it?
Sign of constrictive pericarditis -> rise in systemic VENOUS pressure during INSPIRATION (opposite normal)
-> due to increase in venous flow but no compliance of RV to accommodate increased venous volume (restrictive disease)
What abnormal heart sound is associated with constrictive pericarditis? How is it told apart from S3?
Pericardial knock - due to early and abrupt cessation of ventricular filling
Happens in early diastole like S3, but it is higher frequency
What is the medical and surgical management of constrictive pericarditis?
Medical - Diuretics and salt restriction (reduce volume overload)
Surgical - Pericardiectomy - only definitive treatment
