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Internal Medicine pt.1 > Pericardial disease > Flashcards

Pericardial disease Flashcards

1
Q

What are the layers of the pericardium?

A
  • serous pericardium: increases fluid production in response to injury (contains fibrin & inflammatory cells)
  • fibrous pericardium: attached to diaphragm
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2
Q

What is the difference between acute & chronic pericarditis?

A

inflammation of the pericardium

acute: < 3 months
chronic: > 3 months (constrictive & effusion-constriction)

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3
Q

What are the causes of pericarditis?

A 
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
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4
Q

What are the clinical features of acute pericarditis?

A
  • 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
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5
Q

What are the clinical features of chronic constrictive pericarditis?

A
  • jugular vein distention
  • KUSSMAUL SIGN
  • hepatic vein congestion
  • peripheral edema & ascites
  • fatigue
  • dyspnea on exertion
  • tachycardia
  • pericardial knock
  • pulsus paradoxus (more common in tamponade)
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6
Q

What’s the difference between chronic constrictive & effusive-constrictive pericarditis?

A

same features but pericardial effusion in effusive-constrictive pericarditis

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7
Q

What is the criteria for the diagnosis of acute pericarditis?

A

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
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8
Q

What are the ECG changes that will occur in pericarditis?

A
  • 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)
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9
Q

What is the first line of diagnosis of pericarditis?

A

echocardiography

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10
Q

What are the lab tests done for pericarditis diagnosis?

A
  • leukocytosis
  • increase in troponin (minimal)
  • increase in ESR
  • increase in CRP
  • increase in creatinine kinase
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11
Q

What are the indications for pericardiocentesis?

A
  • large effusions
  • tamponade
  • suspected malignant or purulent pericarditis

do fluid analysis to know what the cause is

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12
Q

What are diagnostic findings of effusive-constrictive pericarditis?

A
  • pericardial effusion

- pericardial thickening

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13
Q

What will be seen on ECHO in chronic constrictive pericarditis?

A
  • increase pericardial thickness
  • abnormal ventricular filling with sudden halt during early diastole
  • variation in ventricular filling with inspiration
  • moderate biatrial enlargement
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14
Q

What findings will be seen on CT & MRI & chest x-ray?

A

pericardial thickening & calcifications

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15
Q

What are the findings of cardiac catheterization in chronic pericarditis?

A
  • elevation of diastolic pressure in ventricles
  • equalization of diastolic pressure in ventricles
  • dip & plateau pressure patterns (SQUARE ROOT SIGN)
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16
Q

How is pericarditis managed?

A
  • 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
17
Q

What is pericardial effusion?

A

accumulation of fluid in pericardial space between parietal & visceral pericardium
- could be acute or chronic

18
Q

elevated intrapericardial pressure from acute pericardial effusion that leads to compression of the heart is known as?

A

Cardiac tamponade

- especially right ventricle compression or collapse

19
Q

What are the causes of hemopericardium?

A
  • cardiac wall rupture
  • chest trauma
  • aortic dissection
  • cardiac surgery
20
Q

What are the causes of serous or seroanguinous pericardial effusion?

A
  • idiopathic
  • acute pericarditis (esp. viral)
  • malignancy
  • postpericardiotomy syndrome
  • uremia
  • autoimmune disorders
  • hypothyroidism
21
Q

What is the pathophysiology of cardiac tamponade?

A

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

22
Q

What are the clinical features of pericardial effusion?

A
  • 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
23
Q

What are the clinical features of cardiac tamponade?

A
  • 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
24
Q

What should be done to diagnose cardiac tamponade?

A
  • in all STABLE patients: confirm with ECHO
  • in UNSTABLE patients: treat immediately
  • analyze pericardial fluid to know the cause
25
Q

What is the gold standard for diagnosis of cardiac tamponade?

A

Echo

  • anechoic space between pericardium & epicardium
  • may show collapsed chamber or swinging motion of the heart
26
Q

What will be seen on ECG of pericardial effusion & cardiac tamponade?

A
  • sinus tachycardia
  • low voltage QRS complex
  • electrical alternans
  • pulseless electrical activity (PEA) in cardiac arrest
27
Q

What is seen one x-rays of pericardial effusion & cardiac tamponade?

A
  • water bottle sign (large pericardial effusion)

- CT & MRI are very accurate but unnecessary

28
Q

How is the pericardial fluid analyzed?

A

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
29
Q

How should pericardial effusion be managed?

A
  • 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
30
Q

How should cardiac tamponade be managed?

A

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
31
Q

What are the complications of pericardiocentesis?

A
  • perforation of internal organs of vasculature

- pericardial decompression syndrome

32
Q

When is surgical management indicated in cardiac tamponade?

A
  • traumatic
  • purulent
  • located
  • rapidly reaccumulating
  • malignant effusions

pericardiotomy (continuous drainage into pleural space or externally) or pericardiectomy

Internal Medicine pt.1 (33 decks)

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