Pericardial Disease Flashcards
What are the 3 functions of the pericardium?
- Fixes heart within the mediastinum, limiting its motion
- Prevents extreme dilatation of the heart during sudden rises of cardiac volume
- Barrier to spread of infection from adjacent structures
3 causes of infectious acute pericarditis.
- Viral (most common)
- TB
- pyogenic bacteria
2 connective tissue conditions that can cause non-infectious acute pericarditis.
- SLE
2. Rheumatoid Arthritis
What causes both early and late pericarditis secondary to MI?
Early: inflammatory response to necrotic heart tissue
Late: autoimmune reaction to necrotic tissue
Name the 7 drugs that can lead to acute pericarditis.
Lupus-like side effects
- Procainamide (class 1A AA)
- Hydralalzine (direct vasodilator)
- Methyldopa (alpha-2 agonist)
- Isoniazide (TB antibiotic)
- Phenytoin (class 1B AA)
Misc.
- Minoxidil (direct vasodilator)
- Anthracycline (chemotherapy)
Auscultatory hallmark of acute pericarditis.
Pericardial Friction Rub
-best heard on left sternal border when HR is less than 120
How does acute pericarditis present in EKG?
At least one lead containing both ST elevation and PR depression
Best treatment for acute viral pericarditis.
Rest
NSAIDs
(oral steroids or colchicine if NSAIDs don’t work)
Best treatment for acute TB pericarditis
TB therapy
Tx for purulent pericarditis.
Drainage and antibiotics
Tx for uremic pericarditis
Dialysis
Tx for pericarditis post MI.
ASA, avoid other NSAIDs and steroids
Most useful test to diagnose pericardial effusion.
Echo
A variety of symptoms can present with pericardial effusion. What is the reason for variety?
Rate of effusion determines the symptoms. Slow rates can be asymptomatic, fast rates can cause dyspnea, fatigue, or chest discomfort.
(volume and compliance can also affect symptoms)
What is the Ewart Sign?
Maybe the only physical exam sign for pericardial effusion.
Dullness to percussion over the angle of the left scapula due to compression of the left lung by the enlarged pericardial sac
What are 2 EKG signs that may be evident with pericardial effusion?
- Low Voltage
2. Electrical Alternans (alternating large and small QRS complexes)
How does pericardial effusion appear on CXR?
Water bottle appearance if large enough.
Modality of choice to diagnose pericardial effusion.
Echo
What is the treatment for pericardial effusion?
Treat underlying cause.
If cause is unknown or a pericardial tamponade, pericardiocentesis
What is cardiac tamponade?
Cardiac chamber compression due to pericardial effusion.
What is a normal pulsus paradoxus?
Drop in systolic blood pressure due to inspiration. Normal is approx 10mmHg.
Why does cardiac tamponade cause a larger/exaggerated pulsus paradoxus?
Compression on the chambers causes an even further deviation of the IV septum into the left ventricle due to expansion of the RV during inhalation. This decreases SV increasing the pulsus paradoxus.
How can cardiac tamponade lead to confusion or agitation?
Lower SV decreases perfusion to the brain.
What are common physical findings with cardiac tamponade?
Beck Traid
- Hypotension
- JVD
- Muffled Heart Sounds
Other signs:
exaggerated pulsus paradoxus (greater than 10mmHg), tachycardia, chest discomfort
Test of choice for cardiac tamponade.
Echo
What will cardiac catheterization show with cardiac tamponade?
All chambers will have equal pressure
Right atrial tracing will have a blunted “y” descent due to impaired ventricular expansion and ability to receive blood from the atria.
What is the definitive treatment for cardiac tamponade?
Pericardiocentesis
-can also give IV fluids and (+)inotropic drugs to improve cardiac output
Functionally, how does constrictive pericarditis differ from cardiac tamponade?
CT: ventricular filling is impaired all thru diastole
CP: ventricular filling is only impaired in mid-late diastole because the restriction only occurs once the ventricles expand to a certain size
What used to be the major cause for constrictive pericarditis?
TB
-he said it’s a popular board question
What is the best modality for diagnosis of constrictive pericarditis?
H+P
What are common signs and symptoms of constrictive pericarditis?
Similar to R. sided heart failure
- lower extremity edema
- abdominal fullness, fatigue, dyspnea
Signs: pericardial “knock”, Kussmaul sign, JVD
What is the pericardial “knock”.
Heart sound that occurs with constrictive pericarditis. It is caused by the heart contacting the non-compliant pericardium during rapid filling of early diastole.
What is the Kussmaul Sign?
Present in constrictive pericarditis. The rigid pericardium prevents the transmission of intrathoracic pressure to the right side of the heart. Results in:
no abnormal pulsus paradoxus
Jugulovenous pressure increases in inspiration
(these two signs allow CP to be differentiated from tamponade)
What is the treatment for Constrictive Pericarditis?
Pericardiectomy: removal of the pericardium
Electrolyte restriction for symptoms.
