pericardial disease Flashcards
give a description of the pericardium
- double layered sac
- exerts a restraining force
- restricts the anatomic position of the heart
- decreases spread of infections from lungs/pleural cavities to the heart
what is pericarditis
inflammation of the pericardial sac
what are possible infectious causes of pericarditis
- viral (MC)
- bacterial (rare, usuallt pulm infection)
- TB (rare in developed countries)
what are systemic disease etiologies for pericarditis
- hypothyroidism
- inflammatory disease (SLE, RA< Scleroderma, sarcoidosis, IBD, polymyositis, ect)
- CKD (uremic pericarditis)
what percent of pericarditis is caused by cancer?
5-10% due to cancers/neoplasms entering pericardium via blood, lymph or direct penetration
Lung CA and Breat CA make of over half of cancer pericarditis patients
RCC, leukemia, lymphomas, and malignant myelomas make up the other half
what could be causes of drug induced pericarditis
- PCN and cromolyn sodium (induce hypersensitivity rxn)
- anthracycline chemo agents (doxorubicin, cyclophophsamide) have cardiac toxicity
- procainamine, hydralazine, mathyldopa, isoniazid develop drug-induced lupus leading to pericarditis
- phenytoin and minoxidil - unknown mechanism
what could be the cause of pericarditis via pericardial injury
- invasive cardiac procedures
- post-pericardiotomy
- trauma
- radiation
what could be the cause of pericarditis via myocardial injury
- post MI
- post-cardiotomy
- trauma
How soon after an MI can pericarditis occur? what does this indicate?
- this usually indicates a LARGE MI
- occurs 2-5 days following MI
- dressler syndrome - occurs 2 weeks later due to delayed autoimmune/inflammatory response.
what are the four principle diagnostic features of pericarditis
- chest pain
- pericardial friction rub
- EKG
- percardial effusion
what is the cardinal symptom of pericarditis and what causes it
- chest pain!
- caused by rubbing of the heart against the pericardium
what is the description of the chest pain that is felt in pericarditis? describe:
location
quality
aggravating factors
intensity
relieving factors
- precordial/retrsternal with referral to trapezius, neck, left shoulder or arm
- pleuritic (worse with deep breathing) but can range from sharp/dull/aching/burning
- wose when lying flat, swallowing, coughing and with movement
- intensity can be very mild or very severe
- may be relieved by sitting up and leaning forward.
what symptoms aside from chest pain could occur in a patient with pericarditis.
- dyspnea (especially with effusion)
- fever
what physical exam finding is common in pericarditis
pericardial friction rub
how is pericarditis diagnosed
typically clinically! any labs ordered are directed at the CAUSE of the pericarditis
what labs could be ordered for pericarditis?
- viral titers/panels (if warranted)
- cardiac enzymes (elevated if myocardium is envolved)
- echo (should be normal unless effusion)
- CBC - (elevated WBC)
- BMP, TFT, ESR, CRP
what may be seen on EKG for pericarditis
- ST elevation (diffuse in ant/inf leads with reciprocal aVR ST depression)
- PR depression (diffuse in ant/inf leads with reciprocal PR elevation in aVR)
- T wave inversion (only seen sometimes)
flip this and youll see an EKG example of pericarditis!:)
flip this and youll see an example of STEMI vs pericarditis EKG
what causes the ST-T and the PR changes in pericarditis
the generalized inflammation of the pericardium thus affecting both ventricles (ST-Tchanges) and the atria (PR changes)
how does a CXR present in pericarditis
typically normal, unless an underlying malignancy or lung process is identified, or a large effusion is present
when is CT or MRI necessary in pericarditis
when malignancy is suspected
what are the essentials of diagnosis for pericarditis?
- anterior pleuritic chest pain worse supine than upright
- pericardial rub
- fever common
- ESR or inflammatory CRP usually elevated
- ECG reveals diffuse ST seg elevation with assocaited PR depression
(idk how this differs from the four diagnostic feature on card 10, so maybe take a look for yourself)
what are the goals of management for pericarditis
- Determine inpatient or outpatient treatment
- Treat symptoms / resolve the inflammation
- Prevent recurrence
- Address underlying cause if possible
what is the treatment of pain and inflammation in pericarditis
- NSAIDS first line (ibuprofen or indomethacin 3-4 weeks)
- ASA should be used in post MI cases for 3-4 weeks
be sure to taper these down over hte last 2 weeks!
what are the indications for inpatient treatment of pericarditis
- Fever > 100.4 (38.3)
- Subacute onset
- Immunosuppression
- Trauma
- Oral anticoagulation therapy
- ASA or NSAID treatment failure
- Myopericarditis
- Large pericardial effusion or tamponade
what is used in recurrence prevention of pericarditis
- colchicine as adjuvant therapy (3 months)
- corticosteroids (severe/refractory cases where NSAIDS and colchicine are not tolerated. also in inflammatory or autoimmune eitologies)
what is the treatment for TB etiologic pericarditis
Standard anti-TB drug regimen is treatment of choice
what is the treatment of choice in uremic ESRD etiologic pericarditis
- dialysis
- NSAIDS for pain/fever
what eitology has very poor prognosis in pericarditis
malignancy
what is pericardial effusion/tamponade
fluid between the paricardial space and tissues
this picture is so cute!
what does “tamponade” mean
a state of increased pressure
what characterizes cardiac tamponade
Characterized by elevated intrapericardial pressure, leading to decreased venous return and ventricular filling = Reduced Cardiac output
MEDICAL EMERGENCY!!
what are the clinical presentations of small/large cardiac effusion
- small - likely no symptoms or just symptoms of pericarditis
- large - no longer has CP of pericarditis but now has fatigue and SOB
- if hemodynamically significant (tamponade) - will have signs of cardiogenic shock
what is beck’s triad for pericardial clinical presentation of tamponade
- distant/muffled heart sounds
- distended jugular veins (increased JVD)
- hypotension
what is kussmauls sign
Kussmaul’s Sign – increase in JVP on inspiration (instead of the normal decrease).
what is pulsus paradoxus
Pulsus Paradoxus – an inspiratory systolic fall in arterial pressure >12 mmHg during normal breathing (check BP with inspiration) – 70-80% of patients
what are the PE findings in a patient with tamponade
- Tachypnea / DOE
- Air hunger
- Anorexia
- Fatigue
- Dysphagia
- Tachycardia
- Hypotension
- Signs of shock
what are some other associated signs and symptoms of tamponade
what can be seen on the EKG in cardiac tamponade
- Characterized by alternating levels of ECG voltage of the p wave, QRS complex, and T waves.
- This is the result of the heart “swinging” in a large effusion.
- beat to beat variation in QRS amplitude
what can be seen in a CXR of cardiac tamponade
- may be normal
- A flask-shaped, enlarged cardiac silhouette may be the first indication of a large pericardial effusion (200-250 mL of fluid accumulation) or cardiac tamponade.
what is the initial test of choice for detecting pericardial effusions
transthoracic echo (TTE)
when checking for tamponade what are the 3 things we look for on a transthoracic echo
- RV Collapse
- LV Collapse
- Dilated IVC w/out inspiratory collapse
what would tha advantages of a CT scan be in evaluation of pleural effusion/cardiac tamponade
- shows entire pericardium
- detects pericardial calcifications
what are the advantages of MRI in evaluation of pleural effusion/cardiac tmaponade
- no use of contrast/radiation
- sensitive to pericardial effusion and loculated pericardial effusion/thickening
DOWN SIDE - cant use in patients with arrhythmias
what is the management for a patient with a small effusion
monitor with serial echocardiograms
what patients with effusions require hospital admission?
- large effusions
- hemodynamic compromise
- Fever (>38ºC [100.4ºF]) and leukocytosis
- Immunosuppressed state
- A history of therapy with V-K antagonists
- Acute trauma
- Failure to respond within seven days to NSAID therapy
- Elevated cardiac troponin, which suggests myopericarditis
what is a pericardiocentesis and when is it used
- removing fluid from the pericardium
- used for effusions >250mL or effusions with size increase despite dialysis for 10-14 days, or effeusions with evidence of tamponade
what are complications of pericardiocentesis
fatal cardiac laceration
yeeeeeesssshhhhh…..
what is a pericardial fluid analysis
Analyze for RBCs, total protein, LDH level, adenosine deaminase activity, gram stain, acid-fast, fungal staining, cultures, cytology.
directly investiagated for TB and cytologic studies are performed
what would the fluid in purulent or suppurative pericarditis present as
thin to creamy pus
what would the fluid in uremic pericarditis present as
- thickened pericardial membranes
- adhesions between membranes
- bloody effusions
what would the fluid in hypothyroidism present as
pericardial fluid is often clear with high protein and cholesterol levels and with few cells.
what is pericardial diodesis
installation of chemical or other agents into the pericardial space in order to cause sclerosis of pericardium
(used in recurrent pericardial effusions)
what is a pericardiotomy
incision into the pericardium
what type of pericardiotomy should be used for large effusions that do not resolve
subxiphoid or percutaneous balloon pericardiotomy
how effevtive is a pericardiotomy
97-99%
done under local anesthesia with less complications than pericardiectomy
what is a pericardial window
A surgical procedure to create a fistula - “window” - from the pericardial space to the pleural cavity, allowing the effusion to drain out of the pericardial space into the chest cavity.
can be perfromed with balloon catheter
what is a pericardiectomy and when is it used?
removal of the pericardium.
The most effective surgical procedure for managing large effusions, but since it requires general anesthesia and a thoracotomy, only consider if pericardiotomy can’t be performed or has been unsuccessful.
what is the etiology of constrictive pericarditis
- Inflammation of the pericardium can lead to a thickened, fibrotic, adherent pericardium
- This restricts diastolic filling, which predominantly presents as right heart failure
what are the MCC of constrictive pericarditis in developed and develpoing countries
- developed - radiation, cardiac surgeries, viral pericarditis.
- developing - TB
what are the symptoms of constrictive pericarditis
- progressive dyspnea
- fatigue
- weakness
what are the PE findings in constrictive pericarditis
- Elevated JVP - kussmauls sign
- afib
- signs of R sided HF (edema, ascites, hepatic congestion)
what are the diagnostic studies used to identify constrictive pericarditis
- echo
- CXR
- Cardiac CT/MRI
- cardiac catheter
what does an echo show in constrictive pericarditis
- thickened pericardium
- maybe RV/LV filling changes esp with inspiration
what does a CXR show in constrictive pericarditis
- heart size normal or enlarged
what would Cardiac CT and MRI show in constrictive pericarditis
- pericardial thickening
what is measured by a cardiac catheter
Allows for the simultaneous measurement of intracardiac pressures in the RV and LV, during inspiration and expiration
what is the confirmatory diagnostic evaluation in most cases of constrictive pericarditis
cardiac catheterization
How do you manage constrictive pericarditis
- diuresis is KEY for improvement of symptoms
- surgical pericardiectomy recommended if unresponsive to diuretics
There are practice questions in the powerpoint! dont forget to go through them! i think theyd be helpful:)
