Pericardial Disease Flashcards
1
Q
Anatomy of the Pericardium
- Pericardium
- Visceral pericardium (epicardium)
- Parietal pericardium
- Pericardial fluid
- Ventricle stiffness determination
A
- Pericardium
- Sac that surrounds the heart & proximal portion of great vessels
- Visceral pericardium (epicardium)
- Single-celled layer of mesothelial cells closely adherent to the surface of the heart
- Reflects onto the surface of outer fibrous pericardium
- Parietal pericardium
- Outer layer of the sac
- Fibrocollagenous layer whose inner lining is also lined by mesothelial cells reflected from epicardium
- Pericardial fluid
- Small volume of fluid in the potential space in b/n the two layers of mesothelial cells
- Ventricle stiffness determination
- Myocardium (mostly)
- Endocardium & pericardium (negligibly)
2
Q
Pulmonary Venous Pressure
- Pulmonary venous pressure
- What increases LV stiffness
- Effects of increased LV stiffness on pulmonary venous pressure
A
- Pulmonary venous pressure
- Generated by the RV
- Fills the LV
- Normal pressure = 10 mmHg
- What increases LV stiffness
- Endocardial thickening
- Ex. fibroelastosis of the endocardium
- Myocardial thickening
- Ex. concentric hypertrophy
- Pericardial thickening
- Ex. fibrous thickening or pericardial fluid
- Endocardial thickening
- Effects of increased LV stiffness on pulmonary venous pressure
- Increased LV stiffness
- –> higher pulmonary venous pressure to fill the LV to a normal volume
- –> pulmonary venous hypertension
- –> pulmonary congestion
- –> shortness of breath
3
Q
Systemic Venous Pressure
- Systemic venous pressure
- What increases RV stiffness
- Effects of increased RV stiffness on pulmonary venous pressure
A
- Pulmonary venous pressure
- Generated by venous tone & blood volume
- Fills the RV
- Normal pressure = 5 mmHg
- What increases RV stiffness
- Endocardial thickening
- Ex. fibroelastosis of the endocardium
- Myocardial thickening
- Ex. concentric hypertrophy
- Pericardial thickening
- Ex. fibrous thickening or pericardial fluid
- Endocardial thickening
- Effects of increased RV stiffness on pulmonary venous pressure
- Sodium & water retention
- –> higher systemic venous pressure to fill the RV
- –> systemic venous hypertension
-
–> systemic congestion
- –> elevated jugular venous pressure
- –> enlarged liver
- –> edema of the feet & ascites
-
–> systemic congestion
4
Q
Low Cardiac Output
- What causes low cardiac output
- Symptoms of chronic low cardiac output
- Symptoms of acute low cardiac output
A
- What causes low cardiac output
- Compensatory rise in venous pressure isn’t adequate to maintain stroke volume & cardiac ouptut
- Symptoms of chronic low cardiac output
- Fatigue
- Symptoms of acute low cardiac output
- Hypotension
- Low pulse pressure
- Thready pulse
- Tachycardia
- Sweaty, cold, & clammy hands
- Confusion due to cerebral hypoperfusion
- Renal insufficiency
- Shock liver: cardiogenic shock-death
5
Q
Pulmonary vs. Systemic Venous Pressure
- LV vs. RV stiffness in a normal heart
- Filling pressure in the LV vs. RV
- Effects of a stiffer pericardial sac, fluid filled pericardium, or fibrotic thickened pericardium
A
- LV vs. RV stiffness in a normal heart
- Different & independent of each other
- Filling pressure in the LV vs. RV
- Stiffer LV is filled w/ higher pulmonary venous pressure (10 mmHg)
- Thinner RV is filled w/ lower systemic venous pressure (5 mmHg)
- Effects of a stiffer pericardial sac, fluid filled pericardium, or fibrotic thickened pericardium
- Both ventricles will be equally stiff
- Both ventricles must be filled by elevated & equal pulmonary & systemic venous pressures
6
Q
Acute Pericarditis: Etiologies
- Infective
- Non-infective
A
- Infective
- Viral (coxsackie, HIV)
- Bacterial (pyogenic bacteria, tuberculosis, etc.)
- Fungal (candida)
- Non-infective
- Connective tissue diseases
- Postmyocardial infarction (Dressler’s)
- Postcardiotomy syndrome
- Renal failure (uremia)
- Neoplastic diseases (lung, breast, lymphoma)
- Radiation induced
- Drug induced (procainamide, hydralazine)
- Traumatic (instrumentation, accident)
- Idiopathic
7
Q
Acute Pericarditis: Pathogenesis & Pathology
- Pathogenesis
- Pathology
A
- Pathogenesis
- Vasodilation (transudation of fluid)
- Increased vascular permeability (leakage of protein)
- Leukocyte exudation (neutrophils & mononuclear cells)
- Pathology
- Serous
- Fibrinous
- Hemorrhagic
- Suppurative
- Chylous
8
Q
Acute Pericarditis: Clinical Features, Diagnostic Tests, & Treatment
- Clinical features
- Diagnostic tests
- Treatment
A
- Clinical features
- Pain: worsened by inspiration & lying down, relieved by sitting up & leaning forward
- Dyspnea: common due to shallow breathing limited by pain
- Fever
- Rub: superficial, scratchy, to & fro
- ECG changes: ST elevation w/ upwards concavity, PR depression
- Diagnostic tests
- Echo: presence of fluid supports, absence doesn’t negate
- PPD, RF, ANA
- Search for malignancy
- Pericardiocentesis: low diagnostic yield, reserved for large effusions w/ tamponade
- Treatment
- Pain relief: aspirin, NSAIDs
- Recurring pericarditis: steroids
- Purulent pericarditis: antibiotics, drainage
- Tuberculosis: multidrug antituberculous therapy
- Neoplastic: radiation, chemotherapy
9
Q
Symptoms of Large Effusions
A
- Due to compression of adjoining structures
- Dysphagia
- Hoarseness (recurrent laryngeal nerve compression)
- Hiccups
- Dyspnea
- Ewart’s sign
- Compression of lung –> area of consolidation in teh left ifnrascapular region –> atalectasis –> percussion dullness & bronchial breathing
- Muffled heart sounds
- Reduced intensity of rub
10
Q
Pericardial Effusion: Pathophysiology
A
- Pericardial fluid
- –> increased ventricle stiffness
- –> increased rapidity & quantity of accumulation
- Sudden increase of small amount of fluid
- Slow accumulation of large amount of fluid
- –> high venous pressures
- –> distended atria & ventricles
- –> distended fluid filled pericardium
- –> equal pericardial & venous pressure
- ► pericardial effusion w/ tamponade –> elevated venous (atrial & ventricular diastolic) pressures –> equal venous & pericardial pressures
11
Q
Pericardial Effusion: Hemodynamics
- Systemic & pulmonary venous pressures
- RV diastolic pressure
- RV pressure tracing
- RA pressure tracing
A
- Systemic & pulmonary venous pressures
- aka LV & RV diastolic and LA & RA pressures
- Elevated & equal
- RV diastolic pressure
- Elevated to > 1/3 of RV systolic pressure
- RV pressure tracing
- Early diastolic dip
- RA pressure tracing
- Absent “Y” descent
12
Q
Pulsus Paradoxus
- Definition
- Paradox
- Mechanism
- Inspiration
- Expiration
- Pulsus paradoxus
- Conditions that increase pulsus paradoxus
A
- Definition
- Inspiratory fall in arterial systolic pressure > 10 mmHg
- Qualitatively the same
- Quantitative exaggeration of the normal
- Paradox
- The pulse in all arteries (in the presence of regular & continuing heart motion) becomes very small or disappears entirely in regular intervals (inspiration) & returns immediately (expiration)
- Paradox: discrepancy b/n heart action & arterial pulse
- Mechanism
- Inspiration
- Decreased intrathoracic pressure
- –> pulmonary venous pressure < extrathoracic systemic venous pressure
- –> LV filling < RV filling
- –> decreased arterial systolic pressure
- –> decreased LV SV
- Expiration
- Increased intrathoracic pressure
- –> pulmonary venous pressure > extrathoracic systemic venous pressure
- –> LV filling > RV filling
- –> increased arterial systolic pressure
- –> increased LV SV
- Pulsus paradoxus
- Difference of > 10 mmHG b/n high expiratory & low inspiratory systolic pressure
- Severe tamponade: difference > 20 mmHg
- Inspiration
- Conditions that increase pulsus paradoxus
- Tamponade
- Exaggerated respiratory inspiratory effort (stridor)
- Exaggerated expiratory effort (asthma, COPD)
13
Q
Cardiac Tamponade
- Venous pressure
- Pulsus paradoxus
- Signs of low cardiac output
- Echo
- EKG
- CXR
A
- Venous pressure
- Elevated
- Kussmaul sign: inspiratory increae in venous pressure isn’t present
- Pulsus paradoxus
- Present
- Inspiratory fall in arterial systolic pressure > 10 mmHg
- Signs of low cardiac output
- Low arterial systolic & pulse pressure
- Other signs of shock
- Echo
- Large effusion
- Absence of inspiratory collapse of IVC
- RA & RV collapse
- Inspiratory decrease in mitral valve flow velocity > 25%
- EKG
- Low amplitude
- Electrical alternans
- CXR
- Enlarged heart shadow (water bottle heart)
14
Q
Cardiac Tamponade: Hemodynamics
- Systemic & pulmonary venous pressures
- RV diastolic pressure
- RV pressure tracing
- RA pressure tracing
A
- Systemic & pulmonary venous pressures
- aka LV & RV diastolic and LA & RA pressures
- Elevated & equal
- RV diastolic pressure
- Elevated to > 1/3 of RV systolic pressure
- RV pressure tracing
- Early diastolic dip
- RA pressure tracing
- Absent “Y” descent
15
Q
Cardiac Temponade: Treatment
- Administer
- Don’t administer
A
- Administer
- Pericardiocentesis
- Pericardial window
- Balloon pericardiotomy
- Surgical removal of part or all of the pericardium
- IV fluids
- Isoproterenol
- Don’t administer
- Drugs that cause volume depletion (diuretics)
- Drugs that cause bradycardia (beta blockers)
- Negative inotropes (Ca2+ channel blockers)
- Vasoconstrictors