Lecture 28: Pericardial Diseases and LV Hypertrophy

Question 1

Acute pericarditis: causes (4 categories)

Answer 1

Most common: idiopathic and viral (coxsackie); infections (bacterial, TB), inflammatory (post MI, lupus), other (malignant, uremia, radiation)

Question 2

Acute pericarditis: history

Answer 2

Sharp mid-sternal pain worse with inspiration, coughing, supine position

Question 3

Acute pericarditis: physical findings

Answer 3

Pericardial friction rub

Question 4

Acute pericarditis: ECG (3)

Answer 4

Diffuse ST segment elevation, PR interval depression, PR interval elevation in AVR

Question 5

What ages does pericarditis often present?

Answer 5

Young and healthy (idiopathic or viral)

Question 6

Acute pericarditis: tx for idiopathic/viral

Answer 6

NSAID, colchicine (prevent relapse)

Question 7

What three causes of pericarditis have fairly poor prognoses? What do you do?

Answer 7

Malignant, bacterial, TB; Treat underlying cause

Question 8

Acute pericarditis: complications

Answer 8

Recurrence or pericardial effusion

Question 9

Define pericardial effusion

Answer 9

> 50 mg fluid in pericardial space

Question 10

Pericardial effusion: causes

Answer 10

Pericarditis (any cause), hypothyroidism, idiopathic, trauma, aortic dissection, procedural complications

Question 11

Pericardial effusion is asymptomatic unless?

Answer 11

Hemodynamic compromise (tamponade)

Question 12

Pericardial effusion: history

Answer 12

Possibly pericarditis, dyspnea and low CO if tamponade

Question 13

Pericardial effusion: exam

Answer 13

Distant heart sounds or signs of tamponade

Question 14

Pericardial effusion: X-ray and echo

Answer 14

Enlarged; Echo is best for viewing the pericardial fluid

Question 15

Pericardial effusion: ECG

Answer 15

Normal; maybe electrical abnormalities (QRS complexes with switching axes), maybe low voltage

Question 16

Define low voltage on ECG

Question 17

Pericardial effusion: tx

Answer 17

Sample fluid if etiology is unclear, treat underlying cause

Question 18

T/F: You should drain the effusion fluid

Answer 18

False

Question 19

T/F: Most idiopathic effusions resolve spontaneously

Answer 19

True

Question 20

Define cardiac tamponade

Answer 20

A rise in pericardial pressure causing a decline in CO by decreasing cardiac filling; if pericardial pressure equals LV diastolic pressure, then diastolic pressure is pericardial pressure in all chambers, impairing filling

Question 21

Can cardiac tamponade happen with little fluid?

Answer 21

Yes: if effusion happens quickly

Question 22

Cardiac tamponade: exam

Answer 22

JVD, tachycardia, pulmonary congestion, signs of low CO, pulsus paradoxus

Question 23

What is the most common question related to findings about cardiac tamponade?

Answer 23

Pulsus paradoxus

Question 24

Describe the steps of pulsus paradoxus (3)

Answer 24

Inspiration results in increased RV return –> RV bulges into septum –> compromised LV filling

Question 25

Constrictive pericarditis: exam (2)

Answer 25

Kussmal sign (rise in JVD with inspiration, which is opposite to normal physiology, because RV cannot fill properly, shunting blood back into venous system, increasing pressure); pericardial knock

Question 26

Define constrictive pericarditis

Answer 26

Thickening/calcification/fibrosis of pericardium often resulting from pericarditis, cardiac surgery, or radiation

Question 27

What happens in constrictive pericarditis?

Answer 27

Abnormal passive filling due to constricted chambers that prevent expansion

Question 28

Constrictive pericarditis: history

Answer 28

Fatigue, dyspnea, slowly developing signs of right heart failure (hepatomegaly and ascites)

Question 29

Constrictive pericarditis: exam

Answer 29

Kussmal sign (rise in JVD with inspiration, which is opposite to normal physiology, because RV cannot fill properly, shunting blood back into venous system, increasing pressure)

Question 30

Constrictive pericarditis: X-ray

Answer 30

Sharp white border along heart demonstrating calcified pericarditis

Question 31

Constrictive pericarditis: tx

Answer 31

Surgical stripping of pericardium

Question 32

How does the LV respond to chronic pressure overload?

Answer 32

Concentric hypertrophy and wall thickening (>11 mm) --> increased LV mass

Question 33

ECG in LV hypertrophy

Answer 33

LV leads have increased amplitude: high r waves in I, AVL, V4-V6; deep S waves in AVR, V1-V3; maybe slightly broader QRS due to increased mass (increased length of depolarization)

Question 34

What are some other ECG findings in LV hypertrophy?

Answer 34

Possible ST segment depression in left sided leads (and possible elevaton in V1-V3); left axis deviation; left atrial enlargement: long and notched p-wave in lead II (>120 msec) and negative second portion of p wave in V1

Question 35

Define low voltage on ECG

Answer 35

Less than 5 in limb, less than 10 in precordial

Question 36

Tx for cardiac tamponade

Answer 36

Pericardiocentesis