Lecture 7 Part 2: Pericardial Disease Flashcards
What are the functions of the pericardium?
- Prevents overdilation of the heart chambers.
- Prevents the heart from shifting in the chest.
- Prevents lung infections from infecting the heart.
What are the primary etiologies of pericarditis?
- Idiopathic
- Infectious (Viral MC)
- Systemic diseases (hypothyroidism, inflammatory, CKD)
- Neoplasms
- Drug-induced
- Pericardial injury
- Myocardial injury
Viral is seasonal as well.
All the inflammatory causes are generally autoimmune diseases.
If a bacterial etiology is suspected for pericarditis, what most likely precipitated it?
Lung infection
What two cancers are most likely to cause pericarditis with a cancerous etiology?
- Lung
- Breast
These two make up about 50% of cancerous pericarditis cases.
Overall, cancers cause about 10% of pericarditis cases.
What drugs are likely to induce pericarditis?
- Amoxicillin or cromolyn (Allergy)
- Anthracycline chemo agents (direct cardiac toxicity)
- Procainamide, hydralazine, methyldopa, isoniazid (Drug-induced SLE)
- Phenytoin and minoxidil (unknown)
What is Dressler syndrome?
A syndrome that appears 2 weeks after an MI, resulting in pericarditis/inflammatory response.
What are the 4 primary diagnostic features of pericarditis?
- Chest pain
- Pericardial friction rub
- EKG changes
- Pericardial effusion
2 out of 4 is diagnostic.
EKG changes: Widespread, diffuse STE or PR depression as prof rice taught us!
Can lead to T wave inversion if caught later.
CPEP
What is the mnemonic for pericarditis causes?
- Collagen vascular changes
- Aortic aneurysm
- Radiation
- Drugs (hydralazine)
- Infections
- Acute renal failure
- Cardiac infarction
- Rheumatic fever
- Injury
- Neoplasms
- Dressler’s Syndrome
CARDIAC RIND
What is the CARDINAL symptom of pericarditis?
Chest pain
Usually relieved by leaning forward or sitting up.
How does someone with pericarditis typically present?
- Dyspnea
- Fever
- Pericardial friction rub
- Angina that is relieved by leaning forward
- Sharp, retrosternal pain
What is the first-line pharmacological tx for pericarditis pain and inflammation?
- NSAIDs: Ibuprofen or indomethacin
- ASA should be used post-MI only.
What conditions should make us consider inpatient managment for pericarditis?
- Fever > 38.3C
- Subacute onset
- Immunosuppression
- Trauma
- Oral AC therapy
- ASA/NSAID failure
- Myopericarditis
- Large pericardial effusion or tamponade
What is the pharmacological therapy for preventing pericarditis recurrence?
- Colchicine
- Corticosteroids (for severe or auto-immune etiology)
What happens when a pericardial effusion gets really big?
Cardiac tamponade
What is Beck’s triad?
- Distant/muffled heart sounds
- JVD or increased JVP
- Hypotension
NOT PATHOGNOMONIC for cardiac tamponade
What signs are seen in cardiac tamponade?
- Kussmaul’s sign: increased JVP on inspiration (Normally should decrease)
- Pulsus paradoxus (BIG inspiratory fall in arterial pressure during systole)
What EKG finding is pathognomonic of cardiac tamponade?
Electrical alternans
QRS complex has varying amplitude on each beat.
What sign on a CXR suggests a large pericardial effusion?
Water bottle heart
What is the initial choice of test for detecting pericardial effusions?
TTE
When we get a TTE, what 3 things are we looking for in pericarditis?
- RV collapse
- LV collapse
- Dilated IVC w/o inspiratory collapse
What would prompt us to admit someone to the hospital for pericardial effusions?
- Large effusions
- Fever + leukocytosis
- Immunosuppressed
- Hx of Vit-K antagonists
- Acute trauma
- Failure to respond to 7 days of NSAIDs
- Elevated trop, which suggests myopericarditis
If pericardial fluid returns a thin to creamy pus, what are the most likely etiologies?
Purulent or suppurative.
What is the primary procedure treating for pericardial effusions?
Pericardiocentesis
If pericardial fluid returns high protein and cholesterol, what is the probably underlying etiology?
Hypothyroidism.
What findings might suggest uremic pericarditis?
Adhesions
When is pericardial diodesis used?
Recurrent pericardial effusions
When is pericardiotomy indicated?
Large, recurrent effusions or ones that don’t resolve.
What is a pericardial window?
Makes a window from pericardial space to the pleural space.
When is pericardiectomy indicated?
Large effusions in which a pericardiotomy cannot be performed or was unsuccessful.
What is constrictive pericarditis and what is the primary pathophysiology it results in?
- Thickened, fibrotic, adherent serous pericardium
- Right sided HF due to poor preload.
What is the MCC of constrictive pericarditis in developing countries? Developed?
- Developing: TB
- Developed: Radiation, surgery, viral
How does constrictive pericarditis usually present?
- Progressive dyspnea, fatigue, and weakness
- RHF symptoms
- Kussmaul sign
- Afib is common
What test is generally confirmatory for constrictive pericarditis?
Cardiac catheterization.
What is the primary drug class we use to improve symptoms in constrictive pericarditis?
Diuretics
When is surgical pericardiectomy recommend?
Unresponsive to diuretics
