Diseases of Pericardium

Question 1

A 35 y/o female presents with 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 sternalborder, louder with expiration and leaning forward. EKG is shown.
What might have been seen on the EKG 8 to 10 days ago?

Answer 1

firemans hat throughout

Question 2

biphasic high pitched squeaky sound at the left sternalborder

Answer 2

pericarditis

Question 3

lyme disease

Answer 3

spirocheatal diseases are 3 phases

Question 4

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

Answer 4

Pericardial pain is pleuriticand postural (worse supine, relieved by sitting). It also tends to be substernaland may be associated with dyspnea, fever and rub.

Question 5

What is the most common cause for pericarditis

Answer 5

Usually viral*(coxsackieor echo), though may be TB(subacutewith night sweats, etc), bacterial (toxic), uremia(shaggy/hemorrhagic and exudative), neoplastic (tamponade), Inflammatory reaction/Dresslers(increased SR; days to several moafter MI or surgery), radiation(usually first year), drugs(clozapine), myxedema(cholesterol crystals), and autoimmune (SLE).

Question 6

Three weeks later the patient develops the following EKG and complains of exertionaldyspnea and orthopnea. PE reveals basilar crackles and an occasional rubbing sound over the precordium. The patient has now developed a (an):

Answer 6

if bad enough pericarditis can get to myocardium

see heart block on ekg for endocarditis?

Question 7

What lab abnormalities might be seen in this patient that may have portended the development of pulmonary edema?

Answer 7

Many cases of pericarditis include myocardial involvement (myocarditis) as well as pericardial and thus will be characterized by troponin elevations, heart block, wall motion abnormalities, and CHF

Question 8

Early localized Lyme disease

Answer 8

bulls eye rash

Question 9

Early disseminated Lyme disease

Answer 9

The classic triad of acute neurologic abnormalities is meningitis, cranial neuropathy*, and motor or sensory radiculoneuropathy, although each of these findings may occur alone.
Cardiac involvement with heart block and myopericarditis

Question 10

Late Lyme disease

Answer 10

Oligoarthritis

Bilateral Bell’s palsy. Other causes of bilateral cranial nerve palsies are TB, sarcoid and trauma.

Question 11

Treatment for Pericarditis

Answer 11

• NSAIDs
• Colchicine (he likes this one)
• Azathioprine
• IVIGs
• IL-1 antagonists (anakinra)

Question 12

A 55 y/o male with diabetic renal failure has a BUN of 120 mg/dLand creatinineof 6.2 mg/dL. He presents with dyspnea, fatigue, neck vein distention, muffled heart sounds and BP of 90/70.
1. What is the above triad and what has happened to
this patient?

Answer 12

Beck’s Triad related in this case to a uremic pericardial tamponade.

Question 13

The patient is shown to have a greater than 10 mm drop in systolic blood pressure with inspiration.
2. What is the name for this phenomenon and what is the mechanism for this event during inspiration?

Answer 13

The patient has developed PulsusParadoxus, where there is decreased LV ejection during inspiration due to the high CVP leading to increased RV filling with septalmotion toward the LV, thus limiting LV filling and LVEF. At the same time, inflow across the mitral valve will decrease by 25%.

wehn bp drops 10 mm or more with a deep breath

it occurs with cardiac tamponade

Question 14

Pulsusparadoxuswith inspiratorydrop in systolic pressure. This can
also be seen in

Answer 14

constrictive pericarditis, asthma and COPD as well

Question 15

A jugular venous tracing

Answer 15

a = atrialcontraction
x = atrialrelaxation
v = atrialfilling
y = atrialemptying

Question 16

What is causing the change in the “y” wave? (more flat)

Answer 16

in cardiac tamponade there is not enough room so not enough blood flows into the ventricle so the atrium doesnt empty as much or as fast

Question 17

Pericardial Tamponadeis characterized by

Answer 17

intrapericardialpressures
of > 15 mmHg which restricts venous return and ventricular filling.
acv waves showing lack of y descent can be seen in the LA via
measuring wedge pressures.

Question 18

“Please, Dr Beck, you PAYfor the CT”!

Answer 18

Beck’s triad
Pulsusparadoxus
electrical Alterans
slowed Ydescent
Cardiac Tamponade

Question 19

Treatment for Cardiac Tamponade

Answer 19

Pericardiocentesis

Question 20

A 55 year old female with a remote history of chest trauma presents with fatigue, weakness, elevated JVP, edema, and hepatomegaly with ascites*. Kussmaulsign is present. Chest xrayis shown.

Answer 20

constrictive pericarditis

Question 21

what is kussmaul sign?

Answer 21

In constrictive pericarditis the jugular engorges with inspiration. This is referred to as the Kussmaulsign.(This sign can also be positive in severe COPD, pulmonary hypertension with RV failure, and more rarely in cardiac tamponade).

ot pathonemonic but associate it with constrictive pericarditis

Question 22

What is the characteristic of the JVP wave in a patient with

Answer 22

pericarditiswith
M or W configuration related
to early and abrupt diastolic
filling with rapid (sharp) X and
Y descent.

so much pressure it slams into ventricle and then it plateus bc the wall is stiff

Question 23

What other signs are found in constrictive pericarditis?

Answer 23

• Diastolic pericardial knock (auscultation -like an S3) and “septalbounce” (ECHO) due to rapid early filling in diastole. Also shows decreased mitral inflow.
• “Square root” sign on heart cath(rapid ventricular filling followed by a plateau phase during the rest of diastole) related to the rigid pericardium impairing mid and late diastolic filling resulting in decreased and equal diastolic filling pressures in all the cardiac chambers

Question 24

√CPK

Answer 24

Square root sign in
constrictive pericarditis with
Kussmaulsign

Question 25

Causes of constrictive pericarditis

Answer 25

TB
Post radiation
Cardiac surgery
Viruses (fibrous from inflammation
trauma

Question 26

What other cardiac entities would tend to simulate constrictive pericarditis?

Answer 26

Restrictive cardiomyopathies

LV diastolic dysfunction.

Question 27

Restrictive cardiomyopathies

Answer 27

(amyloidosis, endomyocardialfibrosis, hemochromatosis, sarcoidosis, etc) = decreased ventricular filling

predominantly left sided but it creates pulmonary htn where restrictive does not so meausre pulmonary pressures

Question 28

How does one differentiate CP

from restrictive heart disease?

Answer 28

One must do cardiac catherizationto differentiate constrictive pericarditis (CP) from restrictive cardiomyopathy (RC). The LV end diastolic pressureis unequal (5 mmHg or higher) to the RV diastolic pressure in restrictive cardiomyopathy, whereas they are equal in constrictive pericarditis (square root sign). Also, pulmonary pressure is high in restrictive cardiomyopathy and low in constrictive pericarditis.
BNP -elevated in RC, but normal in CP.
Chest xray–calcification in CP; LA enlargement in RC.
EKG –BBB, hypertrophy, q waves, AV block in RC.

Question 29

Darrows diff between cp and rest hd

Answer 29

in restrictvie cardiomyopathies you dot get the total equalization of pressure in diastole

in both pts get hepatomegaly and edema

Question 30

Treatment for Constrictive Pericarditis

Answer 30

1. Torsemide(not furosemide bc it is not absorbed in the bowel,)bowel edema), thiazides, aldosterone antagonist (ascites).
2. pericardiectomy

Question 31

Summary

Answer 31

Cardiac Tamponade= pulsusparadoxus, electrical alterans, and slow y descent =Dr Beck, “You PAYfor the CT”!
Constrictive Pericarditis = positive Kussmaul, ie. constrictive pericarditis associated with Kussmaulssign = ConstrictivePericarditisKussmaul. Now add the LV or RV tracing of quick plateau of diastolic ventricular pressure = √CPK