Diseases of Pericardium Flashcards
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?
firemans hat throughout
biphasic high pitched squeaky sound at the left sternalborder
pericarditis
lyme disease
spirocheatal diseases are 3 phases
What position causes the pain to be aggravated in this patient? with pericarditis
Pericardial pain is pleuriticand postural (worse supine, relieved by sitting). It also tends to be substernaland may be associated with dyspnea, fever and rub.
What is the most common cause for pericarditis
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).
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):
if bad enough pericarditis can get to myocardium
see heart block on ekg for endocarditis?
What lab abnormalities might be seen in this patient that may have portended the development of pulmonary edema?
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
Early localized Lyme disease
bulls eye rash
Early disseminated Lyme disease
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
Late Lyme disease
Oligoarthritis
Bilateral Bell’s palsy. Other causes of bilateral cranial nerve palsies are TB, sarcoid and trauma.
Treatment for Pericarditis
- NSAIDs
- Colchicine (he likes this one)
- Azathioprine
- IVIGs
- IL-1 antagonists (anakinra)
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?
Beck’s Triad related in this case to a uremic pericardial tamponade.
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?
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
Pulsusparadoxuswith inspiratorydrop in systolic pressure. This can
also be seen in
constrictive pericarditis, asthma and COPD as well
A jugular venous tracing
a = atrialcontraction x = atrialrelaxation v = atrialfilling y = atrialemptying
What is causing the change in the “y” wave? (more flat)
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
Pericardial Tamponadeis characterized by
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.
“Please, Dr Beck, you PAYfor the CT”!
Beck’s triad Pulsusparadoxus electrical Alterans slowed Ydescent Cardiac Tamponade
Treatment for Cardiac Tamponade
Pericardiocentesis
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.
constrictive pericarditis
what is kussmaul sign?
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
What is the characteristic of the JVP wave in a patient with
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
What other signs are found in constrictive pericarditis?
- 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
√CPK
Square root sign in
constrictive pericarditis with
Kussmaulsign
