L15 - Pericardial Disease

Question 1

Chest pain simulates MI but varies w/respiration and radiation to L trapezius ridge. Inc intensity lying flat and inspiration
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 1

A. Acute pericarditis

Question 2

Pericardial rub on auscultation best heard along L sternal border
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 2

A. Acute pericarditis

* Usually best heard along left sternal border but may be anywhere over precordium. May require auscultation in seated, supine and left lateral decubitus positions in order to be heard.
* May be present one moment and not the next. Sometimes louder during inspiration.

In 50% of cases, triphasic (systole, early and late diastole); in 70%, at least systolic and late diastolic components present; in remainder, systolic only

Question 3

EKG May Show Diffuse ST Elevation
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 3

A. Acute pericarditis

Question 4

Inc WBC/ESR/CRP, Occasionally ↑ CPK-MB/Troponin
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 4

A. Acute pericarditis

Question 5

• Neoplasm, Idiopathic Pericarditis, Uremia are the most common causes.
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 5

B. pleural effusion with cardiac tamponade

Other causes include: 
• Anticoagulants (M.I.; Pericarditis) 
• Bacterial Infections 
• Trauma (External; Catheterization) 
• Cardiac Rupture; Aortic Dissection

Question 6

systemic arterial systolic pressure during exhalation more than 10 mmHg higher than during inspiration

Answer 6

Paradoxical Pulse

Question 7

When is paradoxical pulse almost invariably present?
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 7

B. pleural effusion with cardiac tamponade

Question 8

• SOBOE/Orthopnea; Hypotensive Sxs
• Inc RR & HR With Normal to Low BP and Decreased Pulse Pressure
No pulmonary rales
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 8

B. pleural effusion with cardiac tamponade

Question 9

In this condition, total heart volume is fixed but R sided chambers can expand. And during inspiration RH chambers will compress the LH chambers –> dec LV ____________ –> dec in systolic BP –> paradoxical pulse

Answer 9

Stroke volume - B. pleural effusion with cardiac tamponade

Question 10

Elevated JVP and NO Kussmaul sign
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 10

B. pleural effusion with cardiac tamponade

Question 11

Kussmaul sign

1. • when is it positive?
     - When is it negative?

Answer 11

1. height of the JVP does NOT decrease with inspiration (positive) since the heart is constricted and cannot accept the fluid that would usually flow back into the heart during inspiration. - constrictive pericarditis
2. With inspiration, fluid is brought back, dropping venous pressure so height of the JVP will decrease - cardiac tamponade. RH can’t accept more, but LH will accept more to compensate

Question 12

Which of the following is true in lab findings of cardiac tamponade?
A. EKG is very helpful
B. CXR: normal heart size excludes effusion or tamponade
C. Echo: excellent for detection and size of effusion. Also shows diastolic collapse of RA and RV
D. RH catheterization is not used in diagnosis

Answer 12

C is true
A - minimal value
B - Chest X-ray: May Show Enlarged Cardiac Silhouette But Normal Heart Size Does Not Exclude Effusion or Tamponade
D - Right heart catheterization and pericardiocentesis are critical to diagnosis and treatment of this emergency situation.

Question 13

What is a differential diagnosis for cardiac tamponade?

Answer 13

• Cardiomegaly due to multichamber dilatation with hypotension and/or congestive heart failure
- also shows cardiomegaly on chest xray

Question 14

T/F Majority of chronic constrictive pericarditis is due to neoplasm

Answer 14

F - majority idiopathic

Question 15

• Sxs Related To Right Sided Congestion Without Sxs of left sided (pulmonary) congestion
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 15

C. constrictive pericarditis

Question 16

Why is paradoxical pulse not present in constrictive pericarditis?

Answer 16

Both chambers are constricted equally - RH does not compress the LH so SV is not diminished –> no decrease in systolic BP

Question 17

When is BP: normal to decreased with decreased pulse pressure.
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 17

B and C

Question 18

Ascites, hepatomegaly, peripheral edema (i.e. signs that mimic the picture often present with cirrhosis) are present in which pericardial disease?
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 18

C. constrictive pericarditis
○ High venous pressure –> inferior vena cava –> liver –> legs
JVP is NOT elevated in cirrhosis

Question 19

Pericardial (early diastolic) knock is heard in which?
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 19

C. constrictive pericarditis

Question 20

Cine CT or MRI Useful To show __________- in the diagnosis of constrictive pericarditis?

Answer 20

Thickened pericardium

Question 21

• EKG: Low voltage and non-specific T wave changes; 1/3 of cases have atrial
fibrillation
• CXR: heart usually small; lungs clear; 50% show pericardial calcification.

Catheterization: RA, RV Diastolic, LA & LV Diastolic Equal; “Dip & Plateau” Diastolic Pressure Wave Form
A. Acute pericarditis
B. pleural effusion with cardiac tamponade
C. constrictive pericarditis

Answer 21

C. constrictive pericarditis