CVPR 04-04-14 08-09am Pericardial Disease slides - Horwitz Flashcards
Pericardium defn./structure
A fibroelastic sac w/visceral & parietal layers….. The visceral layer dirtectly abuts the epicardium (outer portion of the myocardium) and is contiguous w/the pleura around the lungs…..A very small quantity of fluid is normally present between the two layers (in the pericardial space); However, in certain diseases, large quantities of fluid may accumulate there.
Four types of pericardial disease:
- Acute Pericarditis …. 2. Pericardial Effusion w/out hemodynamic compromise …. 3. Cardiac tamponade (excessive pericardial fluid compresses heart & reduces CO = acute emergency)…. 4. Constrictive Pericarditis (chronic process where pericardium thickens until it compresses the heart & limits CO)
Acute Pericarditis – Causes
Viral illness, CT/autoimmune disease, Uremia, Metastatic tumors
Acute Pericarditis – Presentation
Chest pain of sudden onset, often severe & sharp, varying w/position & breathing
Acute Pericarditis – Dx
Chest pain varies w/position & breathing…. Pericardial rub on cardiac exam (crackling/rubbing that sounds like it’s right up in your ears) that appear & disappear… EKG: Diffuse ST elevation…. ECHO: Pericardial fluid…. Response to anti-inflammatory agents
Acute Pericarditis on EKG
ST segment is elevated (= injury) involving most of the heart (diffuse)
Acute Pericarditis – Treatment
NSAID of choices: Ibuprofen….. other NSAIDs…. Aspirin….. Colchicine
Pericardial effusion – Causes
Viral or acute idiopathic pericarditis, Metastatic malignancy, Uremia, Autoimmune disease, HypOthyroidism
Pericardial effusion – mechanism of pericardial tamponade
While small pericardial effusions may be asymptomatic, moderate to large effusions cause high intrapericardial pressure —> compression & impaired filling of the right heart —> decreased right ventricular output [lungs are NOT congested] —> Inspiration decreases pressure, allowing increased RV filling, but since it can’t expand in the free wall, it impinges on the LV —> decreased stoke volume, paradoxical pulse, fall in systolic pressure during inspiration, ACUTE EMERGENCY
Pericardial effusion – Symptoms
Asymptomatic w/small effusion & minimal intrapericardial pressure…. Cardiac tamponade w/ large effusion & high intrapericardial pressure = decrease SV, paradoxical pulse w/fall in systolic pressure >10mmHg during inspiration (EMERGENCY)….. NO wet lung symptoms
Pericardial effusion – Dx
Best diagnosed by X-ray or esp. Echocardiogram; Also ECG findings…. X-ray = Enlarged heart W/OUT congested lung field…. ECHO: Collapse of Rt. Atrium and Rt. Ventricle in end-diastole + Dilation of inferior vena cava w/out the normal >50% reduction during inspiration (intrapericardial & venous pressures are very high)….. ECG: Nonspecific = Low voltage w/sinus tachycardia + Electrical alternans reflecting movement of heart back & forth w/in sea of fluid w/each beat (seen as decreased QRS every other beat)
Pericardial effusion/tamponade vs. Dilated cardiomyopathy
Pericardial effusion/tamponade presents with enlarged heart and UN-CONGESTED lungs (b/c of decreased RV output as a result of pressure)….. Dilated cardiomyopathy presents with a dilated heart associated w/pulmonary venous congestion, edema, etc.
Constrictive Pericarditits – Mechanism/Pathophysiology
Cardiac surgery, Radiation, Infection —> SCARRING & LOSS of ELASTICITY of the pericardium (usually takes time to develop, even years) —> Impaired diastolic filling w/normal systolic function
Constrictive Pericarditits –Presentation
MARKEDLY elevated JVP (some of the highest you’ll see)….. ALWAYS Tachycardia….. often Hepatomegaly, Edema, Ascites (from hig venous pressure; often misdiagnosed as liver disease)….. Lungs NOT congested b/c constriction selectively impairs filling of RV (low output)
Constrictive Pericarditits –Dx
Echocardiogram or X-ray ….. Normally-size cardiac silhouette encased by thickened (or calcified) pericardium; Lungs NOT congested (selective RV filling impairment)….. MRI/CT also see pericardial thickening
Constrictive Pericarditits –filling curve
Filling occurs very abruptly in early diastole, w/little or no further filling later in diastole, unlike in normal filling curves (“Dip & Plateau” or “square root sign”)….. Also, the diastolic filling pressures are very high & equalized between Rt. & Lt. ventricles, whereas normally, diastolc RV pressure is much lower than diastolic LV pressure
Constrictive Pericarditits –Treatment
Surgical stripping of the pericardium (hard procedure, but completely cures)
Pericardial pain – distinguishing features
Pericardial pain is (1) “pleuritic” (aggravated by deep breathing) & (2) “positional” (relieved by sitting up or other postural changes)
Pericardial pain vs. Acute coronary syndrome pain
Pain from acute coronary syndromes is not altered by breathing, cough or positional changes, as pericardial pain is
Pericardial pain vs. Acute Pulmonary Embolism pain
Both may be pleuritic (aggravated by deep breathing/cough)…..BUT, Acute PE lacks ECG changes of pericarditis, lacks a pericardial rub, and often occurs in conjunction w/recent surgery or after long automobile/plane travel in which DVT (often w/localized tenderness) occurs in the lower extremities
Pericardial pain vs. Pneumonia pain
Both may be pleuritic (aggravated by deep breathing/cough)…..BUT, pneumonia often has localized rales in the lung fields & sputum production
Pericardial Tamponade vs. Congestive Heart Failure - features in common
Both may have Distended neck veins, Tachycardia, HypOtension, Large cardiac silhouette on xray
Pericardial Tamponade vs. Congestive Heart Failure - timing of impairment
Tamponade = major impairment is in right heart filling during diastole ….. CHF = usually no impairment in right heart filling
Pericardial Tamponade vs. Congestive Heart Failure - lung findings
Tamponade = NO lung congestion ….. CHF = diminished myocardial function causes congestion systemically and in lungs (rales, redistribution of blood flow to upper lobes)
Pericardial Tamponade vs. Congestive Heart Failure – Pulse findings
Pulsus paradoxus & Low voltage/Pulsus alternans common in tamponade & rare in CHF….. Pulsus paradoxus = decrease >10mmHg in systolic pressure/amplitude during inspiration ….. Pulsus alternans = alternating strong & weak beats (LV systolic impairment)
Pericardial Tamponade vs. Congestive Heart Failure – auscultation/palpation of the heart
Tamponade = heart sounds tend to be distant, apex may not be palpable….. CHF = more common to have normal heart sounds often w/murmurs & an S3, as well as the presence of ventricular lifts
Pericardial Tamponade vs. Congestive Heart Failure - Echocardiograms
Tamponade = large pericardial effusion, right atrial collapse, lack of normal decrease in inferior vena cava diameter ….. CHF = poor contractile function, dilation of the ventricles w/out the distinctive tamponade findings
Pericardial Tamponade vs. Constrictive Pericarditis – features in common
Reduced diastolic function w/ preserved systolic function. ….. JVD…. Tachycardia…. Tendency to hypotension
Pericardial Tamponade vs. Constrictive Pericarditis – on x-ray
Tamponade = large cardiac silhouette on xray….. Constrictive pericarditis = silhouette is often normal & may have pericardial thickening/calcification
Pericardial Tamponade vs. Constrictive Pericarditis – Pulse findings
Pulsus paradoxus is present in tamponade & uncommon in constriction.
Pericardial Tamponade vs. Constrictive Pericarditis – time to develop
Tamponade = tends to develop more quickly….. Constrictive pericarditis = typically develops very slowly over considerable time
Pericardial Tamponade vs. Constrictive Pericarditis – systemic findings
Constrictive pericarditis = often accompanied by hepatic congestion, ascites & marked pedal edema ….. these findings are uncommon in tamponade which tends to develop more quickly.
Pericardial Tamponade vs. Constrictive Pericarditis. - Echocardiogram
Tamponade = Pericardial fluid, Right atrial collapse w/inspiration ….. absent in Constrictive pericarditis
