Lecture 28: Pericardial Diseases and LV Hypertrophy Flashcards
Acute pericarditis: causes (4 categories)
Most common: idiopathic and viral (coxsackie); infections (bacterial, TB), inflammatory (post MI, lupus), other (malignant, uremia, radiation)
Acute pericarditis: history
Sharp mid-sternal pain worse with inspiration, coughing, supine position
Acute pericarditis: physical findings
Pericardial friction rub
Acute pericarditis: ECG (3)
Diffuse ST segment elevation, PR interval depression, PR interval elevation in AVR
What ages does pericarditis often present?
Young and healthy (idiopathic or viral)
Acute pericarditis: tx for idiopathic/viral
NSAID, colchicine (prevent relapse)
What three causes of pericarditis have fairly poor prognoses? What do you do?
Malignant, bacterial, TB; Treat underlying cause
Acute pericarditis: complications
Recurrence or pericardial effusion
Define pericardial effusion
> 50 mg fluid in pericardial space
Pericardial effusion: causes
Pericarditis (any cause), hypothyroidism, idiopathic, trauma, aortic dissection, procedural complications
Pericardial effusion is asymptomatic unless?
Hemodynamic compromise (tamponade)
Pericardial effusion: history
Possibly pericarditis, dyspnea and low CO if tamponade
Pericardial effusion: exam
Distant heart sounds or signs of tamponade
Pericardial effusion: X-ray and echo
Enlarged; Echo is best for viewing the pericardial fluid
Pericardial effusion: ECG
Normal; maybe electrical abnormalities (QRS complexes with switching axes), maybe low voltage
Define low voltage on ECG
Pericardial effusion: tx
Sample fluid if etiology is unclear, treat underlying cause
T/F: You should drain the effusion fluid
False
T/F: Most idiopathic effusions resolve spontaneously
True
Define cardiac tamponade
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
Can cardiac tamponade happen with little fluid?
Yes: if effusion happens quickly
Cardiac tamponade: exam
JVD, tachycardia, pulmonary congestion, signs of low CO, pulsus paradoxus
What is the most common question related to findings about cardiac tamponade?
Pulsus paradoxus
Describe the steps of pulsus paradoxus (3)
Inspiration results in increased RV return –> RV bulges into septum –> compromised LV filling
Constrictive pericarditis: exam (2)
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
Define constrictive pericarditis
Thickening/calcification/fibrosis of pericardium often resulting from pericarditis, cardiac surgery, or radiation
What happens in constrictive pericarditis?
Abnormal passive filling due to constricted chambers that prevent expansion
Constrictive pericarditis: history
Fatigue, dyspnea, slowly developing signs of right heart failure (hepatomegaly and ascites)
Constrictive pericarditis: exam
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)
Constrictive pericarditis: X-ray
Sharp white border along heart demonstrating calcified pericarditis
Constrictive pericarditis: tx
Surgical stripping of pericardium
How does the LV respond to chronic pressure overload?
Concentric hypertrophy and wall thickening (>11 mm) –> increased LV mass
ECG in LV hypertrophy
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)
What are some other ECG findings in LV hypertrophy?
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
Define low voltage on ECG
Less than 5 in limb, less than 10 in precordial
Tx for cardiac tamponade
Pericardiocentesis
