CV - pericardial disease

Question 1

describe the pericardium

Answer 1

the pericardium is a fibroelastic sac with visceral (directly abutting the epicardium) and parietal layers, forming a sac containing a small quantity of pericardial fluid

Question 2

what is the purpose of the pericardium?

Answer 2

to reduce the friction produced by the contraction and expansion of the heart

Question 3

what are the four types of pericardial disease?

Answer 3

acute pericarditis
pericardial effusion without hemodynamic compromise
cardiac tamponade
constrictive pericarditis

Question 4

what are the four commonest causes of acute pericarditis?

Answer 4

viral illness
connective tissue or autoimmune disease
uremia/advanced renal dysfunction
metastatic tumors

Question 5

what is the commonest presentation of acute pericarditis?

Answer 5

sudden onset chest pain - often severe, varying with position and breathing

Question 6

what are five diagnostic exam findings or study findings commonly associated with acute pericarditis?

Answer 6

chest pain varies with position or breathing
pericardial rub on cardiac exam
EKG - diffuse ST elevation
ECHO - pericardial fluid
response to anti-inflammatory agents (ibuprofen, aspirin, colchicine)

Question 7

what are the typical drug therapies for acute pericarditis?

Answer 7

ibuprofen 300-800 mg po every 6 to 8 hours
aspirin 325-650 mg

hallmark of treatment now: aspirin and colchicine

Question 8

what is the definition of acute pericarditis?

Answer 8

acute inflammation of the pericardium, most common pericardial disease

Question 9

what is the definition of pericardial effusion?

Answer 9

abnormal accumulation of fluid in the pericardial cavity

Question 10

what are the five commonest causes of pericardial effusion?

Answer 10

viral or acute idiopathic pericarditis
metastatic malignancy
uremia
autoimmune disease
hypothyroidism

Question 11

how does pericardial effusion present on chest X-ray?

Answer 11

enlarged heart

non-conjested lung fields

Question 12

what are the diagnostic exam findings or study findings commonly associated with pericardial effusion?

Answer 12

small effusions without high intrapericardial pressure may be asymptomatic
large effusions with high intrapericardial pressures cause cardiac tamponade where myocardial compression impairs diastolic filling

Question 13

what is the basic definition of pericardial or cardiac tamponade?

Answer 13

pressure on the heart due to a buildup of fluid, blood, pus or gas in the pericardial sac

Question 14

what effect does pericardial tamponade have on heart function?

Answer 14

high intrapericardial pressure results in impaired filling of the right side of the heart, and decreased right ventricular output

Question 15

what is the primary difference between pericardial tamponade and dilated cardiomyopathy?

Answer 15

in pericardial tamponade there is decreased right ventricular output and therefore the lungs are not congested
in dilated cardiomyopathy, the dilated heart is associated with pulmonary venous congestion in the lungs

Question 16

what is the primary cause of constrictive pericarditis?

Answer 16

scarring and loss of elasticity of the pericardium

Question 17

what are the four common etiologies of the scarring and loss of elasticity of the pericardium that cause constrictive pericarditis?

Answer 17

idiopathic
following cardiac surgery
radiation
infectious causes

Question 18

what is the common presentation of constrictive pericarditis?

Answer 18

elevated jugular venous pressure
hepatomegaly
edema
ascites
tachycardia

Question 19

what are the diagnostic exam findings associated with constrictive pericarditis?

Answer 19

thickened or calcified pericardium on Xray
cardiac silhouette usually normal in size but encased by thickened pericardium
lungs not congested on Xray
in catheterization lab measure LV and RV pressures, observe dip and plateau during diastole, equalization of diastolic pressures between LV and RV

difficult to diagnose, often diagnosed by cardiac MRI

Question 20

what is the distinguishing symptomatic feature that distinguishes pericardial pain from other causes of chest pain?

Answer 20

pericardial pain is “pleruitic” meaning it is aggrivated by deep breathing, and is “positional” meaning it is relieved by sitting up or other postural changes

Question 21

pain from acute coronary syndromes is not altered by ____________, ____________ or ____________.

Answer 21

breathing
cough
positional changes

Question 22

pain from acute pulmonary embolus may be pleuritic but lacks the ____________ and ____________ of pericarditis.

Answer 22

electrocardiographic changes

pericardial rub

Question 23

how is pericardial tamponade distinguished from congestive heart failure (CHF)?

Answer 23

in tamponade, the major impairment is in the right heart filling during diastole and there is therefore no pulmonary congestion
in congestive heart failure there is usually no impairment in right heart filling but a generalized diminished myocardial function which causes both pulmonary and systemic congestion

Question 24

in tamponade, the major impairment is with ____________ filling during ____________.

Answer 24

right heart

diastole

Question 25

in congestive heart failure (CHF), there is usually no impairment in right heart filling but diminished ____________ function.

Answer 25

myocardial

Question 26

what are four common features shared by tamponade and CHF?

Answer 26

distended neck veins tachycardia low blood pressure large cardiac silhouette on xray

Question 27

what are the significant exam and X-ray findings that distinguish cardiac tamponade and CHF?

Answer 27

in tamponade the lungs are typically clear on physical exam and X-ray in CHF the lungs are congested with the presence of rales on exam and redistribution of blood flow to the upper lobes, along with other X-ray findings

Question 28

____________, ____________ and ____________ are expected in tamponade and rare in CHF.

Answer 28

pulsus paradoxus low voltage pulsus alternans

Question 29

define pulsus paradoxus

Answer 29

abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration with inspiration there is increased venous return to the right ventricle and the right ventricle expands more quickly. if there is a decrease in the pericardial expandability or an increase in pericardial pressure (pericardial tamponade), the expansion of the right ventricle causes a compression on the left ventricle and a resultant decrease in systolic blood pressure

Question 30

define pulsus alternans

Answer 30

physical finding with arterial pulse waveform showing alternating strong and weak beats, indicated of left ventricular systolic impairment

Question 31

what are three distinctive echocardiogram findings associated with cardiac tamponade?

Answer 31

large pericardial effusion right atrial collapse lack of normal decrease in inferior vena cava diameter

Question 32

what are three common features shared by pericardial tamponade and constrictive pericarditis?

Answer 32

reduced diastolic function with preserved systolic function jugular venous distension tachycardia and tendency to low blood pressure

Question 33

what are the distinguishing differences between pericardial tamponade and constrictive pericarditis?

Answer 33

tamponade has a very large cardiac silhouette on X-ray, whereas the silhouette apparent in constrictive pericarditis is typically normal with pericardial calcification pulsus paradoxus is present in tamponade and uncommon in constrictive pericarditis tamponade tents to exhibit a more rapid onset than constrictive pericarditis echocardiogram findings of pericardial fluid, right atrial collapse with inspiration are typical of tamponade but absent in constrictive pericarditis

Question 34

tamponade has a ____________ on X-ray.

Answer 34

large cardiac silhouette

Question 35

constrictive pericarditis xray findings are often ____________ and may have ____________.

Answer 35

normal cardiac silhouette | pericardial calcification

Question 36

____________ is present in tamponade and uncommon in constrictive pericarditis.

Answer 36

pulsus paradoxus

Question 37

constrictive pericarditis typically develops ____________ and is often accompanied by ____________, ____________ and ____________.

Answer 37

very slowly hepatic congestion ascites marked pedal edema

Question 38

the echocardiogram findings commonly found in tamponade are ____________ and ____________.

Answer 38

large pericardial effusion | right atrial collapse with inspiration

Question 39

what is the most common of the four pericardial diseases?

Answer 39

acute pericarditis

Question 40

what minimal amount of fluid may be present to cause an acute pathological state?

Answer 40

100-200ml fluid

Question 41

visceral pericardium comes into contact with the ____________ layer of the parietal pericardium.

Answer 41

fibrous

Question 42

T/F the pericardium may be damaged by inflammation or damage to the lungs.

Answer 42

true

Question 43

T/F you cannot see the normal pericardium on ECHO or Xray.

Answer 43

true

Question 44

what is the most common cause of acute pericarditis?

Answer 44

viral illness

Question 45

in most cases, acute pericarditis involves both ____________ and ____________.

Answer 45

pericardium | myocardium

Question 46

T/F in most cases, acute pericarditis affects the pericardium exclusively.

Answer 46

false

Question 47

describe ST segment elevation

Answer 47

an elevation of the ST segment from the baseline - the ST segment is higher/deviated than the PR segment baseline

Question 48

because it may present similar to an MI or blockage, oftentimes pericarditis is a diagnosis of ____________.

Answer 48

exclusion

Question 49

what is the most common cause of pericardial effusion?

Answer 49

metastatic malignancy

Question 50

T/F many pericardial effusions resolve without treatment.

Answer 50

true

Question 51

pericardial effusions are defined as mild, moderate or severe based on what measurement?

Answer 51

thickness of effusion

Question 52

what structures are the first to be affected by increased intrapericardial pressures, and how are they affected?

Answer 52

left and right atria | collapse during diastole

Question 53

how is the heart rate affected by progressing pericardial effusion?

Answer 53

heart rate increases, tachycardia

Question 54

how is stroke volume affected by progressing pericardial effusion?

Answer 54

stroke volume decreases

Question 55

how is cardiac output affected by progressing pericardial effusion?

Answer 55

stroke volume decreases and heart rate increases to compensate, cardiac output it initially unaffected

Question 56

in severe cases, pericardial effusions may be associated with ____________.

Answer 56

tamponade

Question 57

what is the cause of pericardial effusion associated with tamponade?

Answer 57

rapidly accumulating moderate or large effusions

Question 58

what is the presentation of pericardial effusion with tamponade?

Answer 58

decreased RV diastolic filling during inspiration distended neck veins inspiratory decrease in arterial pressure (paradoxical pulse or pulsus paradoxus) - respiratory variations in blood pressure

Question 59

what is the likely diagnosis if X-ray findings show an enlarged heart with clear/protected lung fields?

Answer 59

pericardial tamponade

Question 60

what is the likely diagnosis if X-ray findings indicate an enlarged heart with congested lungs?

Answer 60

cardiomyopathy

Question 61

what is the effect of cardiac tamponade on the IVC

Answer 61

IVC is dilated and does not compress

Question 62

constrictive pericarditis causes ____________ in diastolic pressures leading to ____________-sided heart failure.

Answer 62

increase | right

Question 63

does symptomatic constrictive pericarditis develop rapidly or slowly?

Answer 63

slowly - takes years to develop

Question 64

how is chronic constrictive pericarditis typically treated?

Answer 64

surgical shaving of the pericardium