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Internal Medicine > JH IM Board Review - Pericardial Disease I > Flashcards

JH IM Board Review - Pericardial Disease I Flashcards

1
Q

What is the normal amount of pericardial fluid?

A

15-50mL.

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2
Q

What is the definition of acute pericarditis?

A

Signs/symptoms of pericardial inflammation that are <1-2weeks in duration.

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3
Q

What is the percentage of pts w/ nonischemic chest pain that have acute pericarditis?

A

5%.

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4
Q

What is the percentage of pts w/ ST elevation on ECG that have acute pericarditis?

A

1%.

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5
Q

What are the major categories of causes of acute pericarditis?

A
  1. Idiopathic.
  2. Infectious.
  3. Neoplastic.
  4. Autoimmune.
  5. Uremia.
  6. Cardiac surgery.
  7. Irradiation.
  8. Traumatic events.
  9. Infarction.
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6
Q

What are the 2 MCCs of acute pericarditis?

A

Viral or idiopathic.

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7
Q

What percentage of pts w/ acute pericarditis will have an audible friction rub?

A

85%.

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8
Q

What is the characteristic auscultatory finding in acute pericarditis?

A

High-pitched scratchy or squeaky sound best heard at the left sternal border at end-expiration w/ the pt leaning forward.

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9
Q

What are the 3 main components of the high-pitched scratchy or squeaky sound of acute pericarditis?

A

They are related to movement of the heart during the cardiac cycle:

Atrial systole ==> Ventricular systole ==> Ventricular diastole.

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10
Q

What are the 2 special syndromes of pericarditis?

A
  1. Dressler.

2. Postpericardiotomy.

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11
Q

What are the 4 stages of ECG in acute pericarditis?

A

Stage I ==> Diffuse ST elevation + PR depression in most leads (except aVR).

Stage II ==> Normalization of the ST segment and PR interval.

Stage III ==> Widespread T inversions.

Stage IV ==> Normalization of the T waves.

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12
Q

What is the physical course of acute idiopathic or viral pericarditis?

A

Usually a benign, self-limited disease that typically resolves within 2 to 6 weeks.

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13
Q

What is the treatment of acute pericarditis?

3

A
  1. NSAIDs.
  2. Colchicine.
  3. Limitation of strenuous physical activity.
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14
Q

What is the timeline of NSAIDs tx?

A

Can begin tapering after 1 to 2 weeks of tx if sx free.

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15
Q

What is the timeline of colchicine tx?

A

0.6-1.2mg twice daily for 3months.

==> Usually well tolerated, reduces symptoms, and decreases rate of recurrent pericarditis.

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16
Q

What is the evidence supporting limitation of strenuous physical activity for 2 to 6months in acute pericarditis?

A

There is none.

17
Q

What is the role of CS in acute pericarditis?

A

AVOID USING THEM — leads to higher rates of recurrent pericarditis, especially during weaning.

==> Can be necessary if refractory sx.

18
Q

What is important to keep in mind about the tx of post-MI pericarditis?

A

Avoid NSAIDs or CS.

19
Q

What is the role of anticoagulants in the tx of acute pericarditis?

A

They should be avoided.

20
Q

What are the hospitalization criteria for acute pericarditis?

(9)

A
  1. Temp >38.
  2. Subacute onset (sx over weeks).
  3. Immunosuppression.
  4. Trauma-induced.
  5. Tx w/ oral anticoagulants.
  6. Myopericarditis.
  7. Imaging suggesting a large pericardial effusion (>20mm in width).
  8. Signs of tamponade.
  9. Concomitant MI.
21
Q

What is the percentage of pts w/ acute pericarditis that develop tamponade?

A

15%.

22
Q

What are the main effects of a pericardial effusion?

A
  1. Limited diastolic filling.
  2. Decreased SV + CO.
  3. Elevated venous pressures.
  4. Decreased BP.
23
Q

What is the Ewart sign?

A

Dullness to percussion and bronchial breath sounds beneath the left scapula caused by compressive atelectasis in the left lower lung field.

24
Q

What are the echo findings that support a dx of tamponade?

4

A
  1. RA (late diastolic) + RV (early diastolic) collapse.
  2. Exaggerated ventricular septal shift.
  3. Marked respiratory variation in Doppler echo inflow velocities across MV and TV (flow velocity paradox) — also seen in constrictive pericarditis.
  4. Enlargement of the IVC — correlates w/ increased jugular vein distention.
25
Q

What is the meaning of an exaggerated ventricular septal shift?

A
  1. An increase in RV volume w/ inspiration shifts the septum toward the LV in diastole.
  2. W/ expiration, a decrease in RV volume shifts the septum to the right.
  3. This pattern of motion, while normal, is exaggerated in pts w/ tamponade, and leads to pulsus paradoxus.
26
Q

What is the effect of tamponade on intrapericardial pressures?

A

It increases them — leading to equalization of RA, diastolic RV, and PCWP.

27
Q

What is the tx of asx pericardial effusions?

A

Even large ones, may be followed indefinitely with serial echo and clinical assessments.

28
Q

What is the only indication of pericardiocentesis in a pericardial effusion?

A

Only needed if fluid sampling is required to establish a dx, especially if sx are suggestive of bacterial infection (ie purulent pericarditis).

29
Q

What is the method of pericardiocentesis?

A

A wide-bore needle is inserted into the epigastrium below the xiphoid process and advanced in the direction of the medial third of the right clavicle.

30
Q

What is the way by which we distinguish a bloody pericardial effusion from accidental puncture of the heart?

A

If the needle is connected to the V lead of an echo monitor, ST elevation is usually seen if the needle touches the EPICARDIUM.

31
Q

What are the 4 main complications of pericardiocentesis?

A
  1. Accidental puncture of the heart.
  2. Arrhythmias.
  3. Vasovagal attack.
  4. Pneumothorax.
32
Q

What are the 2 temporizing measures before pericardial fluid evacuation in tamponade?

A
  1. Expansion of intravascular volume w/ fluids.

2. Administration of vasopressors.

33
Q

What is that may be required for recurrent episodes of pericardial effusion and tamponade?

(5)

A
  1. Repeated pericardiocenteses.
  2. Balloon pericardiotomy.
  3. Surgical creation of a pericardial window.
  4. Surgical pericardiectomy.
  5. Injection of a sclerosing agent into pericardial space to cause adherence of the visceral and parietal pericardium.
34
Q

What is the pericardial knock seen in constrictive pericarditis?

A

Extra heart sound heard in early diastole (mimics an S3), coinciding w/ abrupt cessation in ventricular filling b/c of the rigid pericardium.

35
Q

What is the definitive tx for constrictive pericarditis?

A

Total pericardiectomy (surgical removal of the pericardium).

Internal Medicine (106 decks)

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