January 11, 2016 - Pericardial Disease

Question 1

Pericardial Anatomy

Answer 1

The parietal layer is on the outside and the visceral/serosal/epicardium layer is on in inside. Between these layers is the pericardial space where it is normal to have 20-50mL of pericardial fluid.

Question 2

Function of the Pericardium

Answer 2

1. Stabilization of the heart within the thoracic cavity
2. Protection of the heart from mechanical trauma and infection from adjoining structures
3. The pericardial fluid functions as a lubricant and dicreases friction of cardiac surface during systole and diastole
4. Prevention of excessive dilation of the heart, especially durinng a sudden rise in intra-cardiac volume

Question 3

Pericarditis

Answer 3

Inflammation of the pericardial layers

Often characterized by sharp, pleuritic chest pain. Pain is classically improved by sitting up (increases space between the pericardial layers), and worse with laying down.

On physical exam you may be able to hear a friction rub (sounds like velcro).

Question 4

Etiology of Pericarditis

Answer 4

1. Idiopathic

2. Post-viral

3. Post-MI (Dressler’s)

4. Autoimmune disease

5. Uremia
6. Radiation
7. Drugs
8. Malignancy

Question 5

ECG Pericarditis

Answer 5

Diffuse ST-elevation with PR-depression.

Question 6

Complications of Pericarditis

Answer 6

1. Pericardial tamponade
2. Pericardial constriction
3. Recurrences

Question 7

Treatment of Pericarditis

Answer 7

Treat the underlying cause, if present.

Anti-inflammatory medicine such as high-dose ASA, NSAIDS, and colchicine.

Question 8

Pericardial Effusion

Answer 8

An abnormal accumulation of pericardial fluid (over 50mL) in the pericardial space.

This may occur from a variety of reasons that is very similar to the etioliogy of pericarditis, however the top 4 are… Malignancy is higher on the list

1. Post-viral
2. Idiopathic

3. Malignancy

4. Autoimmune

Question 9

Consequences of Too Much Pericardial Fluid

Answer 9

With an increase in pericardial compliance and pressure, the heart has a tougher time beating and must work harder to pump blood.

Question 10

Symptoms of Pericardial Effusion

Answer 10

None

Dyspnea

Chest pain (+/-)

Edema

Question 11

Pericardial Effusion - Physical Exam

Answer 11

None

Tachycardia

Low BP

Elevated JVP

Quiet (muffled) heart sounds

Pulsus paradoxus

* Those three are known as Beck’s triad

Question 12

Beck’s Triad

Answer 12

Seen in pericardial effusion.

Refers to seeing low blood pressure, increased JVP, and quiet (muffled) heart sounds on physical exam.

Question 13

Diagnosis of Pericardial Effusion

Answer 13

Echocardiogram

CT / MRI

CXR

Question 14

Pericardial Tamponade

Answer 14

A pericardial effusion that has accumulated under pressure and is limiting cardiac chamber filling by compressing the underlying chambers.

Results in low-output, hypotension, tachycardia, and JVP.

This is a medical emergency.

Life threatening.

Question 15

Symptoms of Pericardial Tamponade

Answer 15

Patient looks unwell

Tachycardic

Hypotensive

Pulsus paradoxus

Elevated JVP

Quiet heart sounds

Question 16

Pulsus Paradoxus

Answer 16

The drop in blood pressure on inspiration of >10 mmHg.

Everybody’s blood pressure will drop on inspiration, but in a healthy individual this will be less than 10 mmHg.

Mechanism: on inspiration, there is a decrease in intra-thoracic pressure, so more blood flows into the right side of the heart. This decrease in pressure also expands the pulmonary vasculature, leading to a drop in blood pressure.

Question 17

ECG Pericardial Tamponade

Answer 17

Low-voltage, sinus tachycardia, with electrical alternans.

Electrical alternans is where the QRS complexes vary in size. One large one, then one small one, then one large one, etc. Look at Leads below.

Question 18

Treatment of Pericardial Tamponade

Answer 18

Drainage by needle (pericardiocentesis) or by surgery.

Fluid is sent for investigation which yields a diagnosis 30% of the time.

Question 19

Pericardial Constriction

Answer 19

Compression of the cardiac chambers by a stiff, thickened, fibrotic, contracted pericardium. This limits the heart’s ability to function normally.

Results in elevated and equal pressures in the cardiac chambers. This results in low stroke volume, and therefore low cardiac output.

Question 20

Pericardial Constriction - Physical Exam

Answer 20

Low BP

Tachycardia

Elevated JVP (Kussmaul’s sign, rapid x and y descent)

Quiet heart sounds

Pericardial knock

Pleural effusion

Ascites (elevated right-sided pressure)

Peripheral edema (elevated right-sided pressure)