Diseases of Pericardium

Question 1

Sharp chest pain which was of sudden onset some 10 days ago. The pain has been less intense over the past week, but worse with inspiration. Two months ago she had a tick bite while hiking in New England. There is a biphasic high pitched squeaky sound at the left sternal border, louder with expiration and leaning forward.

Answer 1

Chronic pericarditis

Question 2

EKG of pericarditis

Answer 2

Inverted T waves

PR interval depression (more concave) -> goes direction opposite of P wave

Question 3

What do inverted T waves mean?

Answer 3

Nonspecific

Question 4

What do symmetrical T waves mean?

Answer 4

More likely to be ischemia

Question 5

What position causes the pain to be aggravated in patient with pericarditis?

Answer 5

Worse supine

Relieved by sitting up

Question 6

Pericardial pain is:

Answer 6

Pleuritic and postural

Tends to be substernal

Question 7

Pericardial pain may be associated with:

Answer 7

Fever, dyspnea, and rub

Question 8

Common causes of pericarditis

Answer 8

Viral
TB
Bacterial
Uremia 
Neoplastic
Inflammatory reaction/Dresslers 
Radiation
Drugs
Myxedema
Autoimmune

Question 9

Viral causes of pericarditis

Answer 9

Coxsackie or echo

Question 10

TB related pericarditis

Answer 10

Subacute

Night sweats

Question 11

Pericarditis due to uremia described as

Answer 11

Shaggy, hemorrhagic, and exudative

Question 12

Neoplastic pericarditis leads to

Answer 12

Tamponade

Question 13

Inflammatory reaction pericarditis

Answer 13

Increased SR

Days to several months after MI or surgery

Question 14

When do you see radiation pericarditis

Answer 14

Within first year

Question 15

Drugs causing pericarditis

Answer 15

Clozapine

Question 16

Myxedema pericarditis

Answer 16

Cholesterol crystals

Question 17

Autoimmune pericarditis

Answer 17

SLE

Question 18

Exertional dyspnea and orthopnea. PE reveals basilar crackles and an occasional rubbing sound over the precordium. EKG shows heart block.

Answer 18

Myocarditis

Question 19

Can pericarditis produce heart block?

Answer 19

No

Need involvement of myocardium

Question 20

Chronic pericarditis can lead to

Answer 20

Myocarditis

Question 21

Pericarditis with myocardial involvement will be characterized by

Answer 21

Troponin elevations, heart block, wall motion abnormalities, and CHF (pulmonary edema)

Question 22

Early disseminated lyme disease

Answer 22

Meningitis, cranial neuropathy (bilateral nerve palsy), and motor or sensory radiculoneuropathy
Heart block and myopericarditis

Question 23

Late lyme disease

Answer 23

Oligoarthritis

Question 24

Other causes of bilateral nerve palsy

Answer 24

TB, sarcoid and trauma

Question 25

A 55 y/o male with diabetic renal failure has a BUN of 120 mg/dL and creatinine of 6.2 mg/dL. He presents with dyspnea, fatigue, neck vein distention, muffled heart sounds and BP of 90/70.

Answer 25

Cardiac tamponade Uremic pericardial tamponade

Question 26

Beck's triad

Answer 26

Increase JVP Decrease BP Muffled heart sounds Tamponade!

Question 27

Pulsus paradoxus

Answer 27

Greater than 10 mm drop in systolic blood pressure with inspiration Decreased LV ejection during inspiration due to the high CVP leading to increased RV filling with septal motion toward the LV, thus limiting LV filling and LVEF Inflow across the mitral valve will decrease by 25%

Question 28

When do you seen pulsus paradoxus

Answer 28

Tamponade | Constrictive pericarditis, asthma and COPD

Question 29

What does JVP tracing look like with cardiac tamponade

Answer 29

Slow decrease and plateau in Y (atrial emptying)

Question 30

What causes dulled Y decent of cardiac tamponade

Answer 30

Intrapericardial pressures of > 15 mmHg restricts venous return and ventricular filling Seen in LA via wedge pressure

Question 31

Left vs Right pressure with cardiac tamponade

Answer 31

Equal

Question 32

Cardiac ECHO in pericardial tamponade

Answer 32

May reveal that during diastole the thinner walled RV collapses

Question 33

“Please, Dr Beck, you PAY for the CT”

Answer 33

``` Beck’s triad Pulsus paradoxus electrical Alterans slowed Y descent Cardiac Tamponade ```

Question 34

Treatment for Cardiac Tamponade

Answer 34

Pericardiocentesis

Question 35

A 55 year old female with a remote history of chest trauma presents with fatigue, weakness, elevated JVP, edema, and hepatomegaly with ascites. Kussmaul sign is present.

Answer 35

Constrictive pericarditis **Elevated JVP, edema, and hepatomegaly with ascites

Question 36

Chest trauma can lead to

Answer 36

Contusion that calcifies -> constrictive pericarditis

Question 37

Kussmaul sign

Answer 37

Jugular engorges with inspiration

Question 38

When do you see Kussmaul sign?

Answer 38

Constrictive pericarditis Severe COPD, pulmonary hypertension with RV failure More rarely in cardiac tamponade

Question 39

JVP tracing of constrictive pericarditis

Answer 39

Short and sharp - M or W configuration Early and abrupt diastolic filling

Question 40

Diastolic pericardial knock

Answer 40

Auscultation sounds like an S3 “Septal bounce” on ECHO due to rapid early filling in diastole Also shows decreased mitral inflow

Question 41

"Square root” sign on heart cath

Answer 41

Rapid ventricular filling followed by a plateau phase during the rest of diastole Rigid pericardium impairs mid and late diastolic filling resulting in decreased and equal diastolic filling pressures in all the cardiac chambers Seen on left and right ventricular tracing

Question 42

Diastolic pericardial know and "square root" sign seen with

Answer 42

Constrictive pericarditis

Question 43

Cause of constrictive pericarditis

Answer 43

``` TB Post radiation Cardiac surgery Viruses Trauma ```

Question 44

What simulates constrictive pericarditis

Answer 44

Restrictive cardiomyopathies (amyloidosis, endomyocardial fibrosis, hemochromatosis, sarcoidosis) -> decreased ventricular filling LV diastolic dysfunction

Question 45

How do you differentiate constrictive pericarditis from restrictive cardiomyopathy

Answer 45

Via cardiac catheterization LV end diastolic pressure is unequal (5 mmHg or higher) to the RV diastolic pressure in restrictive cardiomyopathy, whereas they are equal in constrictive pericarditis (square root sign) **Pulmonary pressure is high in restrictive cardiomyopathy BNP elevated in RC Chest xray – calcification in CP and LA enlargement in RC EKG – BBB, hypertrophy, q waves, and AV block in RC

Question 46

Treatment for Constrictive Pericarditis

Answer 46

Torsemide, thiazides, aldosterone antagonist | Pericardiectomy