Constrictive Pericarditis Flashcards
1
Q
Symptoms
A
- Sx of heart failure (R+L)
- loss of appetite
- fatigue
- palpitations (tachy and AF)
- chronic unproductive cough (pulm HTN)
2
Q
Signs
A
- Cachexia (poor nutrition, protein losing enteropathy, malignancy)
- anasarca (2ry to elevated right heart pressures and cardiac cirrhosis)
- leuconychia (same reason as above)
- Terry nails (3mm brown band at edge of nail bed)
- radiotherapy tattoo marks
- stigmata of chronic liver disease and consequent cardiac cirrhosis including jaundice
- signs of old TB (thoracoplasty with drooping shoulder, thoracotomy for plombage/lobectomy, neck scar for phrenic nerve crush scar)
- Pulse: low volume with regular tachycardia (to maintain CO) or AF (happens in 30% due to biatrial enlargement)
- BP: exaggerated pulsus paradoxis in 1/3. SBP falls by >20mmHg during inspiration as increased RV filling can not be accommodated by the restrictive pericardium so it bulges into LV and reduced LV output
- JVP: markedly raised with marked Y-descent (opening of TV). May be paradoxical rise (or just lack of fall) of JVP during inspiration as RV cannot accommodate more blood (kussmauls sign) (May need to ask pt to stand up to see this)
- Apex: usually impalpable/undisplaced/ doesn’t move with position
- Auscultation
- normal S1
- normal or widely split S2 (early A2 due to pulses paradoxus)
- pansystolic murmur (TR)
- loud S3/pericardial knock. RV fills under high pressure and rapidly in early diastole, this flow suddenly decelerates due to the stiff pericardium and this causes the knocking. It is best heard at left sternal edge, louder with inspiration, higher pitch than other S3’s.
- hepatomegaly and ascites
3
Q
Aetiology
A
- post infectious (eg TB)
- iatrogenic (post-radiation, drug induced (hydralazine, clozapine, procainamide)
- idiopathic
- post-traumatic (haemopericardium)
- autoimmune (SLE)
- uraemia
- neoplastic
4
Q
Investigations
A
- 12 lead ECG: generalised low voltage, p-mitrale, p-pulmonale, tachycardia or AF
- CXR - pericardial calcification, pulmonary congestion, signs of inciting, illness (old TB, post-radiation pneumonitis)
- Echo: thickened pericardium, dilated LA, septal bounce in early diastole, increased variation in valvular flow during respiration (>25% flow variation across tricuspid, >15% across mitral). If all of these negative then <10% chance of diagnosis
- cardiac catheterisation: coronary anatomy prior to possible surgery. Measure right and left heart pressure. RV and LV pressures are characteristically raised and equal. Ventricular pressure falls to zero just at onset of diastole (would normally be at zero for longer). It then rises rapidly and plateaus raised giving trace distinct square root sign. Pulmonary pressures not usually elevated unless secondary process
5
Q
Management
A
- early diagnosis is crucial so underlying cause can be treated
- steroids useful only after TB pericarditis to reduce chance of CP
- diuretics for fluid overload
- avoid beta blockers and rate-limiting calcium channel blockers as tachy is compensatory)
- if AF use digoxin and aim for rate of 90bpm
- no successful long term management. Long term consequences can only be avoided with surgical pericardectomy.
6
Q
Management
A
- early diagnosis is crucial so underlying cause can be treated
- steroids useful only after TB pericarditis to reduce chance of CP
- diuretics for fluid overload
- avoid beta blockers and rate-limiting calcium channel blockers as tachy is compensatory)
- if AF use digoxin and aim for rate of 90bpm
- no successful long term management. Long term consequences can only be avoided with surgical pericardectomy.
