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Cardiology Exam > Pericardial Disease > Flashcards

Pericardial Disease Flashcards

1
Q

jugular venous pulsation

A

*patient lying down in bed around a 45 degree angle, head facing left, looking at the right side of the neck, particularly at the IJ
*recall: there is no valve between the right atrium and the SVC

*estimated right atrial pressure (RAP, in cm of water) = (JVP height) + 5 cm
*normal: 6-8 cm H2O

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2
Q

jugular venous pulsation (JVP) - measurements

A

*A wave = atrial contraction
*C = tricuspid valve closure/systole
*X descent = atrial relaxation
*V wave = venous return
*Y descent = opening of tricuspid valve

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3
Q

jugular venous waveform

A

*A wave = atrial contraction
*C = tricuspid valve closure/systole
*X descent = atrial relaxation
*V wave = venous return
*Y descent = opening of tricuspid valve

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4
Q

differentiating JVP from carotid pulse

A

*for each heartbeat, there are 2 pulsations in the JVP but only 1 in the carotid
*note - if we have atrial fibrillation, there will be no significant “a” wave in the JVP (b/c no p-wave in atrial fibrillation)

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5
Q

pericardium - review

A

*visceral and parietal layers are chief components and separated by the fluid layer
*fibrous/parietal layer innervated by phrenic nerve (visceral layer has no significant innervations)

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6
Q

pericardial agenesis

A

*an extremely rare condition in which the pericardium does not form
*the heart tends to be more translocated into the left side of the chest
*note that people without a pericardium may not have any significant impacts

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7
Q

possible reasons for the pericardium

A

*maintain proper anatomic orientation
*prevent acute dilation of the left ventricle when sudden increase in cardiac volume
*prevent spread of infection from adjacent structures

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8
Q

acute pericarditis - overview

A

*inflammation of the pericardial layers (visceral & parietal)
*most common pericardial ailment

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9
Q

acute pericarditis - symptoms

A

*SHARP STABBING CHEST PAIN, usually located in the precordium, that WORSENS WITH INSPIRATION or lying down (supine)
*fever
*pay particular attention to recent history

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10
Q

acute pericarditis - pathophysiology of symptoms

A

*chest pain worsening with INSPIRATION: expanding lungs rub against an inflamed pericardium
*chest pain worsening when SUPINE: more blood returns to the heart (i.e. heart size increases), and the heart rubs up against an inflamed pericardium

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11
Q

acute pericarditis - physical exam findings

A

*may have a pericardial friction rub caused by the different layers of the inflamed pericardium rubbing against each other
*of note, some rubs have different components: ventricular contraction, ventricular relaxation, atrial contraction

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12
Q

acute pericarditis - diagnostic studies

A

1) 12-lead EKG:
-diffuse ST segment elevation
-PR segment depression (recall line b/w T and P is our baseline)

2) C-Reactive Protein

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13
Q

acute pericarditis - causes

A

*infectious: viral (HIV, COXSACKIE), TB, bacterial
*non-infectious: POST-MI, post-cardiotomy (POST-CABG), uremic (renal failure related), neoplastic
*radiation induced
*connective tissue disease (LUPUS, rheumatoid arthritis, systemic sclerosis)
*drug-related (procainamide, hydralazine, anthracycline chemotherapy, minoxidil)

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14
Q

top causes of acute pericarditis

A

*coxsackie virus
*post-myocardial infarction
*post-CABG
*lupus

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15
Q

acute pericarditis - treatment options

A

*aspirin
*NSAIDs (ibuprofen)
*colchicine
*check an echo to see whether pericarditis may be complicated by a pericardial effusion

note - avoid steroids, as they increase the likelihood that the pericarditis will return

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16
Q

pericardial effusion - overview

A

*abnormal accumulation of fluid in the pericardial cavity, between the visceral and parietal pericardium

note - normally there is 15-50 mL of serous fluid in the pericardial space

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17
Q

3 factors which determine clinical symptoms of pericardial effusion

A
  1. pericardial volume
  2. rate of fluid accumulation (acute vs. chronic)
  3. stiffness of the pericardium
18
Q

pericardial pressure & the RIGHT heart in pericardial effusion

A

*when pressure in pericardium > right atrial pressure, you start to have RIGHT ATRIAL INVERSION (pericardial effusion pushes against and collapses part of the RA)

*when the pressure in pericardium > right ventricular pressure, you start to have DELAYED RIGHT VENTRICULAR FILLING (filling predominantly occurs in late diastole - think P wave)

19
Q

pericardial pressure & the LEFT heart in pericardial effusion

A

*as flow decreases through the right chambers, the left-sided filling starts to exhibit more respiratory variation; right-sided diastolic pressures exceed left-sided → septum deviates toward LV → DECREASED STROKE VOLUME

*as flow decreases through the right chambers, the cardiac output on the left side starts to go down; pt becomes hypotensive, and the body responds by increasing heart rate (becoming tachycardic); this is cardiac tamponade (large effusion compromising CO in a significant way)

20
Q

cardiac tamponade - overview

A

*compression of the heart by fluid (e.g. blood, pleural effusions) → DECREASED CARDIAC OUTPUT
*equilibration of diastolic pressures in all 4 chambers
*should be suspected in any patient with pericarditis, known effusion, or chest trauma who develops volume overload and has signs of decreased cardiac output

21
Q

cardiac tamponade - physical exam findings

A
  1. jugular venous distension
  2. hypotension with pulsus paradoxus
  3. decreased/muffled heart sounds
  4. sinus tachycardia

note: findings 1-3 are known as BECK’S TRIAD

22
Q

cardiac tamponade: JVD

A

*with cardiac tamponade, the X descent (atrial relaxation) is unaffected
*the Y descent is ABSENT (decreased atrial pressure with opening of the tricuspid valve) because:
-the large pericardial effusion is pushing against the right ventricle and making it very difficult to fill

23
Q

cardiac tamponade: PULSUS PARADOXUS

A

*normally, there is a < 10 mmHg drop in systolic BP during inspiration
*in TAMPONADE: there is a drop > 10 mmHg in systolic BP DURING INSPIRATION because of the profound effect of the effusion limiting the size of both the right & left ventricles

24
Q

pulsus paradoxus vs. pulsus alternans

A

*recall: pulsus alternans is when the pulse is stronger every other beat (seen in patients in heart failure with reduced ejection fraction)

*pulsus paradoxus is when you take in a breathe, it shifts the septum toward the left and the pressure goes down, whereas when you breathe out, the pressure goes up

25
Q

cardiac tamponade: pulsus paradoxus - physiology

A

*when one breathes in, there is increased venous return, which means there is increased pressure on the right side to overcome the tamponade squeeze
*because the RV diastolic pressure > LV diastolic pressure, both ventricular and atrial septa bow toward the left

26
Q

cardiac tamponade: electrical alternans

A

*varying heights of the QRS (look at lead II rhythm strip)
*results from the heart “swinging” as a result of the surrounding fluid

27
Q

cardiac tamponade & obstructive shock - pathophysiology

A

cardiac tamponade → reduced filling → low cardiac output → decreased arterial pressure → shock → multiple organ system failure

28
Q

cardiac tamponade - causes

A

*vast majority caused by any kind of acute pericarditis
*additionally, acute hemorrhage into the pericardium, which can be caused by:
-blunt force trauma
-LV free wall rupture secondary to STEMI
-acute aortic dissection

29
Q

cardiac tamponade - treatment

A

*pericardiocentesis (echo-guided) to remove fluid
*often leave in a drain to prevent re-accumulation

note - do NOT drain fluid if the tamponade is due to acute aortic dissection

30
Q

pericardial constriction - overview

A

*scarring and fibrosis of the pericardium with possible calcification → pericardium is extremely stiff

31
Q

pericardial constriction - causes

A

*tuberculosis was the #1 cause in the early 20th century
*now, it is idiopathic; recurrent bouts of pericarditis & left-sided chest radiation are common culprits

32
Q

pericardial constriction - pathophysiology

A

*during filling in the normal heart/pericardium, both can expand
*in pericardial constriction, the stiffness of the pericardium may actually limit the filling of the heart because the pericardium does not expand with the heart
*as blood passes from the right atrium into right ventricle, the RV expands until it reaches the limit imposed by the stiff pericardium; as a result, venous return stops, and venous pressure increases
*if left ventricular expansion is limited, it may limit stroke volume & cardiac output→ low blood pressure

33
Q

pericardial constriction - signs/symptoms

A

*JVD, hepatomegaly, ascites, peripheral edema
*pulmonary rales
*dyspnea
*hypotension & reflexive tachycardia
*KUSSMAUL’S SIGN

34
Q

pericardial constriction - Kussmaul’s Sign

A

*normally when you inhale, more blood should get into the thoracic cavity
*in CONSTRICTION, when the pt inhales, the jugular veins distend b/c the stiff pericardium will not allow more blood to enter the right side of the heart
*SIMPLE: increase in jugular veinous pressure (distention of jugular veins) during inhalation

note - Kussmaul’s sign is NOT part of cardiac tamponade

35
Q

pericardial constriction: pericardial knock

A

*in constriction, a pericardial knock occurs when the ventricles hit the stiff, calcified pericardium and can no longer expand
*“knock” is heard after the S2 heart sound

36
Q

what is Kussmaul’s sign associated with?

A

PERICARDIAL CONSTRICTION

note: Kussmaul’s sign is distention of the jugular veins/increased JVP during INHALATION

37
Q

pericardial constriction: jugular venous pulsation

A

*in constriction, there is a VERY STEEP Y-DESCENT, which indicates pressure really drops when blood moves forward through an open tricuspid valve

38
Q

contrast pericardial constriction vs. cardiac tamponade

A

*jugular venous pulsation:
-STEEP Y-descent = constriction
-absent/decreased Y-descent = tamponade

*Kussmaul’s sign = constriction
*pericardial knock = constriction

*pulsus paradoxus can occur in both, but is more likely in tamponade

39
Q

ventricular interdependence in pericardial constriction

A

*during inspiration, the septum shifts to the left to allow more blood on the right side of the heart (LV becomes smaller, RV becomes larger)
*during expiration, the septum shifts to the right to allow more blood on the left side of the heart

40
Q

pulsus paradoxus in pericardial constriction

A

*NORMAL: when you inspire, blood stays in lungs; normally, LA expands → lowers LA pressure → maintains forward flow to LA

*in CONSTRICTION: LA can’t expand during inspiration → pressure stays elevated → pressure in pulmonary veins drops → lower pressure gradient from lungs to LA → lower left sided stroke volume

41
Q

treatment of significant pericardial constriction

A

*pericardial stripping (pericardial window)

Cardiology Exam (52 decks)

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