Pericardial disease Flashcards
What are the layers of the pericardium?
- serous pericardium: increases fluid production in response to injury (contains fibrin & inflammatory cells)
- fibrous pericardium: attached to diaphragm
What is the difference between acute & chronic pericarditis?
inflammation of the pericardium
acute: < 3 months
chronic: > 3 months (constrictive & effusion-constriction)
What are the causes of pericarditis?
1- post-VIRAL 2- idiopathic 3- acute MI 4- uremia 5- autoimmune connective tissue diseases (SLE) 6- Hodgkin's lymphoma 7- after cardiac surgery 8- radiation 9- trauma
What are the clinical features of acute pericarditis?
- positional chest pain (worse when lying down & relieved by leaning forward)
- pleuritic chest pain
- pericardial friction rub
- low grade fever
- dyspnea, tachypnea, cough
- pericardial effusion
What are the clinical features of chronic constrictive pericarditis?
- jugular vein distention
- KUSSMAUL SIGN
- hepatic vein congestion
- peripheral edema & ascites
- fatigue
- dyspnea on exertion
- tachycardia
- pericardial knock
- pulsus paradoxus (more common in tamponade)
What’s the difference between chronic constrictive & effusive-constrictive pericarditis?
same features but pericardial effusion in effusive-constrictive pericarditis
What is the criteria for the diagnosis of acute pericarditis?
at least 2 of the following should be present
- characteristic chest pain (sharp, pleuritic, worsened by lying down & improved by leaning forward)
- pericardial friction rub
- typical ECG changes (widespread ST elevation & PR depression) & (reciprocal ST depression & PR elevation in aVR & V1) & (sinus tachycardia)
- new or worsening pericardial effusion
What are the ECG changes that will occur in pericarditis?
- STAGE 1: diffuse ST elevations, PR depression, & ST depression in aVR & V1
- STAGE 2: ST segment normalizes in 1 week
- STAGE 3: inverted T waves
- STAGE 4: ECG returns to normal baseline in weeks to months (UNLIKE STEMI)
What is the first line of diagnosis of pericarditis?
echocardiography
What are the lab tests done for pericarditis diagnosis?
- leukocytosis
- increase in troponin (minimal)
- increase in ESR
- increase in CRP
- increase in creatinine kinase
What are the indications for pericardiocentesis?
- large effusions
- tamponade
- suspected malignant or purulent pericarditis
do fluid analysis to know what the cause is
What are diagnostic findings of effusive-constrictive pericarditis?
- pericardial effusion
- pericardial thickening
What will be seen on ECHO in chronic constrictive pericarditis?
- increase pericardial thickness
- abnormal ventricular filling with sudden halt during early diastole
- variation in ventricular filling with inspiration
- moderate biatrial enlargement
What findings will be seen on CT & MRI & chest x-ray?
pericardial thickening & calcifications
What are the findings of cardiac catheterization in chronic pericarditis?
- elevation of diastolic pressure in ventricles
- equalization of diastolic pressure in ventricles
- dip & plateau pressure patterns (SQUARE ROOT SIGN)
How is pericarditis managed?
- first line: NSAID therapy (high dose ASA, ibuprofen, indomethacin) + colchicine
- second line: glucocorticoids (if NSAIDs contraindicated)
- gastro-protective therapy if there’s risk of GI bleeding
- treat underlying cause
- pericardiocentesis when indicated
- surgical pericardiectomy
What is pericardial effusion?
accumulation of fluid in pericardial space between parietal & visceral pericardium
- could be acute or chronic
elevated intrapericardial pressure from acute pericardial effusion that leads to compression of the heart is known as?
Cardiac tamponade
- especially right ventricle compression or collapse
What are the causes of hemopericardium?
- cardiac wall rupture
- chest trauma
- aortic dissection
- cardiac surgery
What are the causes of serous or seroanguinous pericardial effusion?
- idiopathic
- acute pericarditis (esp. viral)
- malignancy
- postpericardiotomy syndrome
- uremia
- autoimmune disorders
- hypothyroidism
What is the pathophysiology of cardiac tamponade?
pericardial fluid collection -> increase pressure in pericardial space -> compression of the heart (esp RV) -> intraventricular septum shift toward the left ventricular chamber -> decrease ventricular diastolic filling -> decrease stroke volume -> decrease cardiac output & equal end diastolic pressures in all 4 chambers
What are the clinical features of pericardial effusion?
- shortness of breath (esp. when lying down) orthopnea
- retrosternal chest pain
- compressive symtoms (hoarseness, dysphagia, hiccups)
- apical impulse is difficult to locate
- Ewart sign: dullness to percussion at the base of the left lung with increased vocal fremitus & bronchial breathing
What are the clinical features of cardiac tamponade?
- Beck’s triad (hypotension, muffled heart sounds, distended neck veins)
- tachycardia, pulses paradoxus
- pallor, cold sweats
- left ventricular failure
- symptoms of right heart failure
- obstructive shock, cardiac arrest
What should be done to diagnose cardiac tamponade?
- in all STABLE patients: confirm with ECHO
- in UNSTABLE patients: treat immediately
- analyze pericardial fluid to know the cause
What is the gold standard for diagnosis of cardiac tamponade?
Echo
- anechoic space between pericardium & epicardium
- may show collapsed chamber or swinging motion of the heart
What will be seen on ECG of pericardial effusion & cardiac tamponade?
- sinus tachycardia
- low voltage QRS complex
- electrical alternans
- pulseless electrical activity (PEA) in cardiac arrest
What is seen one x-rays of pericardial effusion & cardiac tamponade?
- water bottle sign (large pericardial effusion)
- CT & MRI are very accurate but unnecessary
How is the pericardial fluid analyzed?
by pericardiocentesis using LIGHT CRITERIA
- clear -> transudate -> HF,RF, hypoalbuminemia, post radiotherapy
- cloudy, chylous -> exudate -> viral, inflammation, malignancy, autoimmune, chylopericardium
- hemorrhagic -> blood -> post cardiac surgery, cardiac rupture, aortic dissection, TB, malignancy
- thick, yellowish-white, cloud -> purulent -> TB, bacterial infection
How should pericardial effusion be managed?
- if tamponade is present -> urgent pericardial fluid drainage
- if tamponade is not present -> 50-100ml of effusion (small) -> conservative management
- > if >100ml -> consider pericardial fluid drainage
How should cardiac tamponade be managed?
pericardiocentesis in
- hemodynamically unstable patients (as temporizing measure prior to surgery)
- large effusions
- for analysis of fluid in effusion of unknown etiology
- if no resolution with treatment of underlying cause
What are the complications of pericardiocentesis?
- perforation of internal organs of vasculature
- pericardial decompression syndrome
When is surgical management indicated in cardiac tamponade?
- traumatic
- purulent
- located
- rapidly reaccumulating
- malignant effusions
pericardiotomy (continuous drainage into pleural space or externally) or pericardiectomy
