Pericardial disease Flashcards
Four types of pericardial disease
Acute pericarditis, pericardial effusion w/out hemodynamic compromise, cardiac tamponade, constrictive pericarditis
Causes of acute pericarditis
viral, CT disease, autoimmune disease, uremia, metastatic tumors
Acute pericarditis presentation
Severe sudden onset of chest pain that varies with position and breathing
Acute pericarditis diagnostic criteria
Chest pain varies with position, breathing, Pericardial rub on cardiac exam, EKG-Diffuse ST elevation, ECHO-Pericardial fluid, Response to anti-inflammatory agents
Acute pericarditis treatment
Ibuprofen is best. Also aspirin as alternative
Pericardial effusion causes
- Viral or acute idiopathic pericarditis 2. Metastaticmalignancy 3.Uremia (kidney disease) 4.Autoimmune Disease 5.Hypothyroidism
Pericardial effusion diagnosis
X-ray or echo: Enlarged heart w/out congested lungs. Small effusions without high intrapericardialpressure may be asymptomatic. Large effusions with high intrapericardialpressures cause cardiac tamponade where myocardial compression impairs diastolic filling
Pericardial effusion with tamponade causes
rapidl accumulating moderate/large effusions put pressure on the heart
Pericardial effusion w/ tamponade presentation
High intrapericardial pressure impairs filling of right heart, decreasing RV output (thus lungs are NOT congested). Decreased RV diastolic filling during inspiration backs up causing distended neck veins. Also paradoxical pulse (decrease in arterial pressure with inspiration b/c increased filling of RV impinges on the LV lowering SV)
What is pulsus paradoxus
> 10mmHg drop in systolic pressure during inspiration, seen in pericardial effusion
Tamponade Echo
Collapse of right atrium and right ventricle in end-diastole. Dilation of inferior vena cava w/out normal 50% reduction during inspiration
Cardiac tamponade EKG
Low voltage with sinus tachycardia (also seen in pulmonary disease, cardiomyopathy) and electrical alternans with sinus tachycardia
What is electrical alternans
movement of heart back/forth in sea of fluid from pericardium
Cardiac tamponade treatment
Aspiration of fluid
Constrictive pericarditis cause
Scarring & loss of elasticity of the pericardium
Constrictive pericarditis etiologies
Idiopathic, after cardiac surgery, radiation, infectious
Constrictive pericarditis pathophys
Impaired diastolic filling with normal systolic function
Constrictive pericarditis presentation
Markedly elevated jugular venous pressure, tachycardia Often with hepatomegaly,edema, ascites due to prolonged high venous pressure
Constrictive pericarditis diagnosis
Echo, X-ray (thickened or calcifed pericardium), catheterization shows early diastolic filling wave with no further filling plus LV and RV have same filing pressures (normally RV is lower than LV)
Constrictive pericarditis treatment
surgical stripping of pericardium
Why are the lungs not congested in constrictive pericarditis?
constriction selectively impairs filling of RV
Distinguish pericardial pain from other causes of chest pain
The distinguishing symptomatic feature of pericardial pain is that it is “pleuritic” i.e. aggravated by deep breathing and “positional” i.e. relieved by sitting up or other postural changes.
What do Pericardial Tamponade and Congestive Heart Failure have in common
In common: Distended neck veins, tachycardia, low blood pressure, large cardiac silhouette on xray.
Compare lungs in tamponade and CHF
In tamponade the lungs are usually clear on physical exam and xray but in CHF the lungs are congested with presence of rales on exam.
Compare pulsus paradoxus in tamponade and CHF
present in tamponade, not in CHF
Heart sounds in tamponade vs CHF
In tamponade heart sounds tend to be distant and the apex may not be palpable, whereas in CHF it is more common to have normal heart sounds often with murmurs and an S3, and presence of ventricular lifts.
Echo in tamponade vs CHF
In tamponade a large pericardial effusion, right atrial collapse, and lack of normal decrease in inferior vena cava diameter are present. In CHF poor contractile function and dilation of the ventricles are typical
Tamponade and constrictive pericarditis common features
Reduced diastolic function with preserved systolic function, Jugular venous distention, Tachycardia and tendency to low blood pressure
Tamponade vs constrictive pericarditis X-ray
Tamponade has a large cardiac silhouette on xray whereas the silhouette is often normal and may have pericardial calcification in constriction
Pulsus paradoxus in tamponade vs constrictive pericarditis
present in tamponade, not constrictive
Time course of tamponade vs constrictive pericarditis
Constrictive pericarditis typically develops very slowly over considerable time and is often accompanied by hepatic congestion, ascites and marked pedal edema whereas these findings are uncommon in tamponade which tends to develop more quickly
Echo in tamponade vs constrictive pericarditis
The echocardiogram demonstrates pericardial fluid, and right atrial collapse with inspiration in tamponade but these are absent in constriction
