Lecture 32 - Pericardial Disease, Pulmonary Vascular Disease, and Right Heart Function

Question 1

Pericarditis pain typically presents as dull heaviness or sharp pain that worsens with inspiration? Look for New, widespread _____ elevation and/or _____ depression. Patients with ischemic chest pain typically DON’T move around to find a comfortable position. Listen for a superficial scratchy sound over the ____ sternal boarder.

Answer 1

Sharp pain that worsens with inspiration

ST elevation and/or PR depression

Left sternal boarder

Question 2

Patients are susceptible to Pericarditis post-____.

Answer 2

post-MI

Question 3

A major metabolic cause of Pericarditis is end stage _____ failure.

Answer 3

Renal

Question 4

Pericarditis diagnosis requires at least ____ of the following 4 criteria:

1. Pericarditic chest pain
2. Pericardial Friction rub
3. New widespread ____ elevation or ____ prolongation.
4. Pericardial ____.

Answer 4

2

ST elevation or PR prolongation

Pericardial Effusion

Question 5

ST elevation in Pericarditis is in which leads?

Answer 5

ALL OF THEM! (Diffuse ST elevation.)

Question 6

How does the timing of T-wave inversion differ in pericarditis vs MI?

Answer 6

In MI, the T-wave inverts BEFORE ST elevation comes back to baseline.

Question 7

Pericarditis is the most common cause of Pericardial ______, but it can occur WITHOUT Pericarditis. (e.g. with TB infection).

Answer 7

Pericardial Effusion

Question 8

Cardiac ______ results from pericardial effusion that worsens to the point of decreasing cardiac output bc it constricts the heart and decreases filling.

Answer 8

Cardiac Tamponade

Question 9

The size of pericardial effusion is measured as the distance from the Parietal pericardium to the Epicardium.

Mild: < ____ mm
Moderate: ___-___mm
Large: > _____mm

Answer 9

Mild: < 10mm
Moderate: 10-20mm
Large: > 20mm

Question 10

For any volume of Pericardial effusion, how do the pressures differ if it is acute onset vs Chronic (> 3 months) and why?

Answer 10

The pressure will be greater given equal volume in acute bc the pericardium has not be given time to stretch and accommodate the volume.

Question 11

In the presence of a large pericardial effusion, the left heart fills even less during inspiration than normal bc Pulmonary venous pressures fall below Left ventricular pressure. This is called _____ ______.

Answer 11

Pulsus Paradoxus

Question 12

Patients with Large Pericardial effusions will demonstrate Electrical _______ and _____ (high or low?) voltage on EKG.

Answer 12

Electrical Alternans (alternating amplitude of the QRS wave for each beat)

Low Voltage

Question 13

Pericardial Constriction is different than Pericardial Effusion in that Constriction means the pericardium becomes stiff and ______. Progression from Pericarditis to Pericardial Constriction is highest when the Pericarditis was initially caused by what?

Answer 13

Calcified

Bacterial infection, particularly TB (lowest when initially VIRAL infection)

Question 14

Patients with Pericardial Constriction will present with elevated ____ ____ pressure that does not decline with inspiration and about half will present with Pericardial ____. Few patients will present with Pulsus Paradoxus.

Answer 14

Jugluar Venous Pressure

Pericardial Knock

Question 15

Regardless of the Respiratory cycle, the ____ pressures in all compartments of the heart are equal bc the heart is essentially encased in a calcified shell that doesn’t allow it to stretch during filling –> this will appear as a dip and plateau or _____ ____ sign on EKG, as passive filling occurs initially, but then plateaus without Atrial kick (again, no stretch to accommodate filling).

Answer 15

Diastolic pressure are equal

Square Root sign

Question 16

The mainstay procedure to treat Pericardial Constriction is ________.

Answer 16

Pericardiectomy

Question 17

Pericardial masses are rarely primary. Secondary (metastatic) are common from what four cancers?

Answer 17

Lung

Breast

Melanoma

Lymphoma

Question 18

Ventilation Perfusion Scintigraphy is used to identify Pulmonary Embolism (PE). How does it work?

Answer 18

Inhale radiolabled aerosol –> Perfuse with radiolabeled substance –> look for mismatch between perfused areas and ventilation areas (the radiolabeled images from perfusion and ventilation should overlap if there is NO embolism).

Question 19

Supportive diagnostic testing for PE include Serum __-___ level (if it’s low –> no embolism likely) and Lower Limb _____ (looking for clotting in _____ vein.)

Answer 19

Serum D-dimer level

Lower Limb Ultrasound

Femoral Vein

Question 20

The reason PE becomes fatal is when the ____ becomes hypokinetic due to excessively high pressures and ultimately results in drastically decreased CO.

Answer 20

RV

Question 21

Normal mean Pulmonary Arterial Pressure (mPAP) = ___ to ___ mmHg at rest.

mPAP > _____mmHg is considered Pulmonary HTN.

Answer 21

8 to 20 mmHg

> 25mmHg

Question 22

How does the PAP compare to the PVP (Pulmonary Venous Pressure) in Pulmonary Arterial HTN?

Answer 22

PAP is high but PVP remains normal

Question 23

In Pulmonary HTN, are vasoconstrictors or vasodilators elevated, and which one specifically promotes endothelial proliferation? Which are given as treatment?

Answer 23

Vasoconstrictors/proliferators are elevated.

Endothelin

Vasodilators are given as treatment (i.e. NO and Phosphodiesterase inhibitors –> prevent cGMP breakdown).