PERICARDIAL DISEASE Flashcards
Which of the following characteristics best differentiates the chest pain of acute pericarditis from that of acute myocardial infarction (AMI)?
A) Pain radiates to the left arm and jaw
B) Pain is pleuritic and relieved by sitting up and leaning forward
C) Pain is steady and worsened by exertion
D) Pain is most severe at night and relieved by nitroglycerin
Correct Answer: B) Pain is pleuritic and relieved by sitting up and leaning forward
Rationale: The pain of acute pericarditis is often sharp and pleuritic (worsened by inspiration and coughing). It is also characteristically relieved by sitting up and leaning forward, whereas AMI pain is typically steady, pressure-like, and not affected by position. AMI pain may radiate to the left arm and jaw, but this feature is not unique to pericarditis.
A pericardial friction rub, a hallmark of acute pericarditis, is best heard:
A) During deep inspiration with the patient lying supine
B) During forced expiration while the patient is standing
C) At end expiration with the patient upright and leaning forward
D) After exercise, when the heart rate is increased
Correct Answer: C) At end expiration with the patient upright and leaning forward
Rationale: A pericardial friction rub is most commonly described as a rasping, scratching, or grating sound. It is best heard at end expiration when the patient is upright and leaning forward, as this position brings the pericardium closer to the chest wall.
Ewart’s sign, an important clinical finding in pericardial effusion, refers to:
A) A pericardial friction rub heard at the left sternal border
B) A patch of dullness, increased fremitus, and egophony beneath the angle of the left scapula
C) Pulsus paradoxus greater than 10 mmHg during inspiration
D) A high-pitched diastolic murmur due to aortic regurgitation
Correct Answer: B) A patch of dullness, increased fremitus, and egophony beneath the angle of the left scapula
Rationale: Ewart’s sign occurs when a large pericardial effusion compresses the base of the left lung, leading to localized dullness to percussion, increased fremitus, and egophony beneath the angle of the left scapula. This finding can help differentiate pericardial effusion from other causes of cardiomegaly.
What is the first-line treatment for acute idiopathic pericarditis?
A) Glucocorticoids
B) Nonsteroidal anti-inflammatory drugs (NSAIDs)
C) Antibiotics
D) Anticoagulants
Correct Answer: B) Nonsteroidal anti-inflammatory drugs (NSAIDs)
Rationale: NSAIDs, such as aspirin (2–4 g/day) or ibuprofen (600–800 mg three times daily), are the first-line treatment for acute idiopathic pericarditis. Glucocorticoids are reserved for patients who do not tolerate or fail NSAID and colchicine therapy. Antibiotics are used only for bacterial pericarditis, and anticoagulants should be avoided due to the risk of bleeding into the pericardial cavity.
In which patient population is colchicine contraindicated?
A) Patients with a history of recurrent pericarditis
B) Patients with renal or hepatic dysfunction
C) Patients who are taking NSAIDs
D) Patients with a mild pericardial effusion
Correct Answer: B) Patients with renal or hepatic dysfunction
Rationale: Colchicine interferes with neutrophil migration but can cause gastrointestinal side effects, including diarrhea. It is contraindicated in patients with hepatic or renal dysfunction due to the risk of toxicity and impaired drug clearance.
What is the primary role of colchicine in the treatment of acute pericarditis?
A) To provide immediate pain relief
B) To prevent recurrent pericarditis
C) To reduce pericardial effusion size
D) To act as an anticoagulant
Correct Answer: B) To prevent recurrent pericarditis
Rationale: Colchicine (0.5 mg daily for patients <70 kg or 0.5 mg twice daily for patients >70 kg) enhances the response to NSAIDs and reduces the risk of recurrent pericarditis. It does not provide immediate pain relief, reduce pericardial effusion size, or function as an anticoagulant.
Why should anticoagulants generally be avoided in patients with acute pericarditis?
A) They can worsen pericardial inflammation
B) They are ineffective in managing pericarditis symptoms
C) They can cause bleeding into the pericardial cavity, leading to tamponade
D) They interact negatively with NSAIDs
Correct Answer: C) They can cause bleeding into the pericardial cavity, leading to tamponade
Rationale: Anticoagulants increase the risk of bleeding into the pericardial cavity, which can lead to cardiac tamponade, a life-threatening condition. Therefore, they are generally avoided in acute pericarditis unless there is a specific indication.
Which of the following is a predictor of poor prognosis in acute pericarditis?
A) Low-grade fever (<38°C)
B) Presence of a pericardial friction rub
C) Large pericardial effusion
D) Mild pleuritic chest pain
Correct Answer: C) Large pericardial effusion
Rationale: Predictors of poor prognosis in acute pericarditis include fever >38°C, subacute onset, and large pericardial effusion. These factors may indicate a more serious underlying cause (e.g., tuberculosis, neoplastic disease, or bacterial infection) and warrant hospitalization.
Which of the following is NOT a component of Beck’s triad, the classic clinical features of cardiac tamponade?
A) Hypotension
B) Pericardial friction rub
C) Jugular venous distention
D) Muffled heart sounds
Correct Answer: B) Pericardial friction rub
Rationale: The three principal features of tamponade (Beck’s triad) are hypotension,
soft or absent heart sounds, and jugular venous distention with a prominent x (early systolic) descent but an absent y (early diastolic)
descent. The limitations to ventricular filling are responsible for reductions
of cardiac output and arterial pressure.
Which of the following is a hallmark feature of cardiac tamponade on physical examination?
A) Loud first heart sound
B) Increased systolic arterial pressure during inspiration
C) A greater than normal (>10 mmHg) inspiratory decline in systolic arterial pressure
D) A fixed splitting of the second heart sound
Correct Answer: C) A greater than normal (>10 mmHg) inspiratory decline in systolic arterial pressure
Rationale: This feature, known as pulsus paradoxus, is a key finding in cardiac tamponade. It results from increased right ventricular filling during inspiration, which shifts the interventricular septum leftward, reducing left ventricular stroke volume and systolic pressure. Fixed splitting of the second heart sound is seen in atrial septal defects, not tamponade.
Which diagnostic test is most useful in confirming the presence of cardiac tamponade?
A) Chest X-ray
B) Electrocardiogram (ECG)
C) Transthoracic echocardiography
D) Coronary angiography
Correct Answer: C) Transthoracic echocardiography
Rationale: Because immediate treatment of cardiac tamponade may be lifesaving, prompt establishment of the diagnosis, usually by
echocardiography, should be undertaken. In tamponade, there is late diastolic inward motion (collapse) of the right ventricular free wall and the right atrium.
Which clinical sign is strongly associated with cardiac tamponade but is less prominent or absent in other conditions?
A) Kussmaul’s sign
B) Pulsus paradoxus
C) Pericardial knock
D) Third heart sound
Correct Answer: B) Pulsus paradoxus
Rationale: The table indicates that pulsus paradoxus (+++) is a hallmark of cardiac tamponade, whereas it is only sometimes present in constrictive pericarditis (+) and absent in other conditions. Pulsus paradoxus is an exaggerated drop in systolic blood pressure during inspiration due to restricted ventricular filling.
Which of the following conditions is most likely to present with Kussmaul’s sign?
A) Cardiac tamponade
B) Constrictive pericarditis
C) Restrictive cardiomyopathy
D) Right ventricular myocardial infarction
Correct Answer: B) Constrictive pericarditis
Rationale: The table shows that Kussmaul’s sign (+++) (a paradoxical increase in jugular venous pressure during inspiration) is strongly associated with constrictive pericarditis and is also present in restrictive cardiomyopathy (++) and right ventricular infarction (++). However, it is absent in cardiac tamponade (−). This sign indicates impaired right ventricular filling.
Which of the following findings is most suggestive of cardiac tamponade on an electrocardiogram (ECG)?
A) Electrical alternans
B) Low-voltage QRS complexes
C) ST-segment elevation
D) T-wave inversions
Correct Answer: A) Electrical alternans
Rationale: The table indicates that electrical alternans (+++) is a key feature of cardiac tamponade and is rarely present in other conditions. Electrical alternans refers to beat-to-beat variation in QRS amplitude due to the heart “swinging” within a large pericardial effusion.
Which condition is most likely to have a “pericardial knock” on auscultation?
A) Constrictive pericarditis
B) Cardiac tamponade
C) Right ventricular myocardial infarction
D) Restrictive cardiomyopathy
Correct Answer: A) Constrictive pericarditis
Rationale: The table shows that pericardial knock (++) is characteristic of constrictive pericarditis and absent in other conditions. A pericardial knock is an early diastolic sound resulting from the abrupt cessation of ventricular filling due to a non-compliant pericardium.
Which condition is an important differential diagnosis for pericarditis associated with collagen vascular disease?
A) Systemic lupus erythematosus (SLE)
B) Rheumatic fever
C) Ankylosing spondylitis
D) Marfan syndrome
Correct Answer: A) Systemic lupus erythematosus (SLE)
Rationale: The text highlights SLE as a major cause of pericarditis among collagen vascular diseases, alongside rheumatoid arthritis, scleroderma, and polyarteritis nodosa. The presence of antinuclear antibodies (ANA) helps differentiate SLE-related pericarditis from idiopathic pericarditis.
Which type of pericarditis is most commonly associated with severe renal dysfunction?
A) Tuberculous pericarditis
B) Uremic pericarditis
C) Neoplastic pericarditis
D) Purulent pericarditis
Correct Answer: B) Uremic pericarditis
Rationale: The text states that uremic pericarditis occurs in up to one-third of patients with severe renal dysfunction and may also be seen in patients undergoing chronic dialysis (dialysis-associated pericarditis). It is usually fibrinous with serosanguinous effusions, and NSAIDs plus intensified dialysis are the primary treatments.
Which of the following statements about purulent pericarditis is TRUE?
A) It is most commonly caused by viral infections.
B) It often presents without systemic symptoms.
C) It is usually secondary to cardiothoracic surgery or extension of infection.
D) It has a favorable prognosis with antibiotics alone.
Correct Answer: C) It is usually secondary to cardiothoracic surgery or extension of infection.
Rationale: The text states that purulent pericarditis often results from cardiothoracic operations, extension of infections from the lungs or pleura, esophageal rupture, or endocarditis. It is characterized by fever, chills, septicemia, and a poor prognosis unless immediate drainage and antibiotics are initiated.
Which of the following pericarditis causes is associated with mediastinal irradiation for neoplasm?
A) Constrictive pericarditis
B) Uremic pericarditis
C) Purulent pericarditis
D) Mycobacterial pericarditis
Correct Answer: A) Constrictive pericarditis
Rationale: The text states that mediastinal irradiation can cause acute pericarditis and/or chronic constrictive pericarditis. Radiation-induced pericarditis leads to fibrosis and thickening of the pericardium, ultimately restricting ventricular filling.
What is the primary physiological abnormality in chronic constrictive pericarditis?
A) Impaired ventricular contraction due to myocardial infarction
B) Inability of ventricles to fill due to a rigid, thickened pericardium
C) Increased myocardial compliance leading to heart failure
D) Uncontrolled hypertension causing left ventricular hypertrophy
Correct Answer: B) Inability of ventricles to fill due to a rigid, thickened pericardium
Rationale: The fundamental problem in chronic constrictive pericarditis is the restriction of ventricular filling due to a fibrotic, thickened pericardium, which limits cardiac expansion. Unlike cardiac tamponade, where filling is impeded throughout diastole, constrictive pericarditis allows early diastolic filling but abruptly restricts it.
Which jugular venous pulse finding is most prominent in chronic constrictive pericarditis?
A) Absent y descent
B) Prominent x descent only
C) Prominent y descent
D) Kussmaul’s sign absence
Correct Answer: C) Prominent y descent
Rationale: The y descent in the jugular venous pulse represents early diastolic ventricular filling. In constrictive pericarditis, the y descent is pronounced because the ventricles initially fill normally but are suddenly restricted by the rigid pericardium. In contrast, cardiac tamponade shows a diminished or absent y descent.
Which of the following best distinguishes cardiac tamponade from constrictive pericarditis?
A) Both conditions elevate atrial and ventricular diastolic pressures to similar levels
B) Cardiac tamponade exhibits prominent y descent, whereas constrictive pericarditis does not
C) Ventricular filling is impeded throughout diastole in tamponade, but only in late diastole in constrictive pericarditis
D) Both conditions present with Kussmaul’s sign as a major feature
Correct Answer: C) Ventricular filling is impeded throughout diastole in tamponade, but only in late diastole in constrictive pericarditis
Rationale:
Constrictive pericarditis: Early diastolic filling occurs normally but is abruptly stopped when the thickened pericardium reaches its elastic limit.
Cardiac tamponade: Ventricular filling is restricted throughout diastole due to the fluid pressure within the pericardial sac.
Kussmaul’s sign (increased JVP on inspiration) is common in constrictive pericarditis but rare in tamponade.
The “square root” sign in ventricular pressure tracings is a characteristic finding in:
A) Cardiac tamponade
B) Chronic constrictive pericarditis
C) Hypertrophic cardiomyopathy
D) Aortic stenosis
Correct Answer: B) Chronic constrictive pericarditis
Rationale: The “square root” sign represents an initial rapid diastolic filling followed by abrupt cessation due to pericardial constraint. This finding is seen in constrictive pericarditis and restrictive cardiomyopathy, but not in cardiac tamponade.
Which of the following is a key distinguishing clinical feature of chronic constrictive pericarditis?
A) Widened pulse pressure
B) Kussmaul’s sign
C) Loud systolic murmur
D) Bounding peripheral pulses
Correct Answer: B) Kussmaul’s sign
Rationale: Kussmaul’s sign refers to a failure of the jugular venous pressure (JVP) to decline during inspiration. It is commonly seen in chronic constrictive pericarditis, as well as tricuspid stenosis and restrictive cardiomyopathy.
A widened pulse pressure is more characteristic of aortic regurgitation.
Loud systolic murmurs are not a hallmark of constrictive pericarditis.
Bounding pulses are more typical of hyperdynamic circulation (e.g., aortic regurgitation, sepsis, thyrotoxicosis).
A pericardial knock is best described as:
A) A high-pitched diastolic sound caused by abrupt cessation of ventricular filling
B) A loud first heart sound due to delayed mitral valve closure
C) A mid-systolic click caused by mitral valve prolapse
D) A continuous murmur due to pericardial friction rub
Correct Answer: A) A high-pitched diastolic sound caused by abrupt cessation of ventricular filling
Rationale: A pericardial knock is an early diastolic heart sound heard in chronic constrictive pericarditis. It results from the sudden halt of ventricular filling due to the rigid pericardium. It can sometimes be confused with S3, but it occurs earlier in diastole.
A loud first heart sound (B) is characteristic of mitral stenosis.
A mid-systolic click (C) is associated with mitral valve prolapse.
A continuous murmur (D) is typically due to pericardial friction rub or patent ductus arteriosus (PDA).
Which ECG finding is most commonly associated with chronic constrictive pericarditis?
A) ST-segment elevation in all leads
B) Low QRS voltage and T-wave flattening
C) Delta waves and short PR interval
D) Right bundle branch block
Correct Answer: B) Low QRS voltage and T-wave flattening
Rationale: The ECG in chronic constrictive pericarditis commonly shows low voltage of QRS complexes due to the thickened pericardium preventing normal electrical conduction. Diffuse T-wave flattening or inversion is also seen.
ST-segment elevation in all leads (A) is more characteristic of acute pericarditis.
Delta waves and a short PR interval (C) are seen in Wolff-Parkinson-White (WPW) syndrome.
Right bundle branch block (D) may be seen in various cardiac diseases but is not a primary feature of constrictive pericarditis.
Which imaging modality is the most definitive for diagnosing chronic constrictive pericarditis?
A) Chest X-ray
B) Transthoracic echocardiography (TTE)
C) Computed tomography (CT) or cardiac MRI
D) Stress echocardiography
Correct Answer: C) Computed tomography (CT) or cardiac MRI
Rationale:
CT and MRI are the most accurate imaging modalities for diagnosing constrictive pericarditis because they can clearly visualize pericardial thickening, calcification, and fibrosis.
Chest X-ray (A) may show pericardial calcifications but lacks sensitivity for diagnosis.
Transthoracic echocardiography (B) can provide indirect evidence, such as pericardial thickening and abnormal ventricular filling patterns, but cannot definitively confirm or exclude the diagnosis.
What is the only definitive treatment for chronic constrictive pericarditis?
A) Long-term corticosteroids
B) High-dose diuretics
C) Pericardial resection (pericardiectomy)
D) Pericardiocentesis
Correct Answer: C) Pericardial resection (pericardiectomy)
Rationale:
Pericardiectomy (pericardial resection) is the only definitive treatment for chronic constrictive pericarditis. The goal is to remove as much of the thickened, fibrotic pericardium as possible to restore normal ventricular filling.
