JH IM Board Review - Pericardial Disease I Flashcards
What is the normal amount of pericardial fluid?
15-50mL.
What is the definition of acute pericarditis?
Signs/symptoms of pericardial inflammation that are <1-2weeks in duration.
What is the percentage of pts w/ nonischemic chest pain that have acute pericarditis?
5%.
What is the percentage of pts w/ ST elevation on ECG that have acute pericarditis?
1%.
What are the major categories of causes of acute pericarditis?
- Idiopathic.
- Infectious.
- Neoplastic.
- Autoimmune.
- Uremia.
- Cardiac surgery.
- Irradiation.
- Traumatic events.
- Infarction.
What are the 2 MCCs of acute pericarditis?
Viral or idiopathic.
What percentage of pts w/ acute pericarditis will have an audible friction rub?
85%.
What is the characteristic auscultatory finding in acute pericarditis?
High-pitched scratchy or squeaky sound best heard at the left sternal border at end-expiration w/ the pt leaning forward.
What are the 3 main components of the high-pitched scratchy or squeaky sound of acute pericarditis?
They are related to movement of the heart during the cardiac cycle:
Atrial systole ==> Ventricular systole ==> Ventricular diastole.
What are the 2 special syndromes of pericarditis?
- Dressler.
2. Postpericardiotomy.
What are the 4 stages of ECG in acute pericarditis?
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.
What is the physical course of acute idiopathic or viral pericarditis?
Usually a benign, self-limited disease that typically resolves within 2 to 6 weeks.
What is the treatment of acute pericarditis?
3
- NSAIDs.
- Colchicine.
- Limitation of strenuous physical activity.
What is the timeline of NSAIDs tx?
Can begin tapering after 1 to 2 weeks of tx if sx free.
What is the timeline of colchicine tx?
0.6-1.2mg twice daily for 3months.
==> Usually well tolerated, reduces symptoms, and decreases rate of recurrent pericarditis.
What is the evidence supporting limitation of strenuous physical activity for 2 to 6months in acute pericarditis?
There is none.
What is the role of CS in acute pericarditis?
AVOID USING THEM — leads to higher rates of recurrent pericarditis, especially during weaning.
==> Can be necessary if refractory sx.
What is important to keep in mind about the tx of post-MI pericarditis?
Avoid NSAIDs or CS.
What is the role of anticoagulants in the tx of acute pericarditis?
They should be avoided.
What are the hospitalization criteria for acute pericarditis?
(9)
- Temp >38.
- Subacute onset (sx over weeks).
- Immunosuppression.
- Trauma-induced.
- Tx w/ oral anticoagulants.
- Myopericarditis.
- Imaging suggesting a large pericardial effusion (>20mm in width).
- Signs of tamponade.
- Concomitant MI.
What is the percentage of pts w/ acute pericarditis that develop tamponade?
15%.
What are the main effects of a pericardial effusion?
- Limited diastolic filling.
- Decreased SV + CO.
- Elevated venous pressures.
- Decreased BP.
What is the Ewart sign?
Dullness to percussion and bronchial breath sounds beneath the left scapula caused by compressive atelectasis in the left lower lung field.
What are the echo findings that support a dx of tamponade?
4
- RA (late diastolic) + RV (early diastolic) collapse.
- Exaggerated ventricular septal shift.
- Marked respiratory variation in Doppler echo inflow velocities across MV and TV (flow velocity paradox) — also seen in constrictive pericarditis.
- Enlargement of the IVC — correlates w/ increased jugular vein distention.
What is the meaning of an exaggerated ventricular septal shift?
- An increase in RV volume w/ inspiration shifts the septum toward the LV in diastole.
- W/ expiration, a decrease in RV volume shifts the septum to the right.
- This pattern of motion, while normal, is exaggerated in pts w/ tamponade, and leads to pulsus paradoxus.
What is the effect of tamponade on intrapericardial pressures?
It increases them — leading to equalization of RA, diastolic RV, and PCWP.
What is the tx of asx pericardial effusions?
Even large ones, may be followed indefinitely with serial echo and clinical assessments.
What is the only indication of pericardiocentesis in a pericardial effusion?
Only needed if fluid sampling is required to establish a dx, especially if sx are suggestive of bacterial infection (ie purulent pericarditis).
What is the method of pericardiocentesis?
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.
What is the way by which we distinguish a bloody pericardial effusion from accidental puncture of the heart?
If the needle is connected to the V lead of an echo monitor, ST elevation is usually seen if the needle touches the EPICARDIUM.
What are the 4 main complications of pericardiocentesis?
- Accidental puncture of the heart.
- Arrhythmias.
- Vasovagal attack.
- Pneumothorax.
What are the 2 temporizing measures before pericardial fluid evacuation in tamponade?
- Expansion of intravascular volume w/ fluids.
2. Administration of vasopressors.
What is that may be required for recurrent episodes of pericardial effusion and tamponade?
(5)
- Repeated pericardiocenteses.
- Balloon pericardiotomy.
- Surgical creation of a pericardial window.
- Surgical pericardiectomy.
- Injection of a sclerosing agent into pericardial space to cause adherence of the visceral and parietal pericardium.
What is the pericardial knock seen in constrictive pericarditis?
Extra heart sound heard in early diastole (mimics an S3), coinciding w/ abrupt cessation in ventricular filling b/c of the rigid pericardium.
What is the definitive tx for constrictive pericarditis?
Total pericardiectomy (surgical removal of the pericardium).
