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icm-cardio > Pericardial disease > Flashcards

Pericardial disease Flashcards

1
Q

pericardium

A

visceral and parietal layer with pericardial cavity between them

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2
Q

how much fluid is in the pericardium?

A

15-50ml

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3
Q

pericarditis

A

inflammation of pericardium

  • acute and recurrent pericarditis
  • pericaridal effusion without major hemodynamic compromise
  • cardiac tamponade
  • constrictive pericarditis
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4
Q

acute pericarditis

A

rapidly inflammation of pericardium

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5
Q

causes of pericarditis

A 
radiation
neoplasms: primary, metastatic, or paraneoplastic 
trauma
autoimmune
metabolic: hypothyroidism, uremia
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6
Q

infection causes

A

viral
Bacterial:
fungal:
AIDS

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7
Q

infection causes: viral

A

coxsackie, echovirus, mumps, adeno, HIV

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8
Q

bacterial causes

A

TB, pneuomococcus, strept, staph, legionella

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9
Q

infection causes: fungal

A

histoplasmosis, coccidioidomycosis, candida, blastomycosis

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10
Q

cardiac causes of pericarditis

A
  • early infarction
  • late post cardiac injury (Dressler’s)
  • myocarditis
  • resulting from dissecting aortic aneurysm
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11
Q

drugs that cause pericarditis

A

procainamide
isoniazide
hydralazine

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12
Q

etiology of acute pericarditis

A 
most idiopathic
vial
neoplastic
TB/histoplasmosis
radiation
purulent (bacterial)
connective tissue disease
post-myocardial infarction
uremia
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13
Q

pathological anatomy of acute pericarditis

A
  • usually fluid accumulation
  • bacterial or tumor
  • sometimes bacterial infection causes purulent pericarditis
  • fluid may resolve or form adhesions
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14
Q

chest pain

A

present most the time
sudden onset
anterior chest wall
sharp, pleuritic in nature: inflammation of lining of lungs
worse with laying flat, inspiration or coughing
better when seated, leaning forward

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15
Q

presentation of acute pericarditis

A

chest pain (unrelated to exertion)
fatigue, dyspnea, malaise
fever
-can mimic onset of the flu

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16
Q

what causes the pericardial friction rub

A

friction between the two inflamed layers of pericardium

  • scratchy, leathery sound-> high pitch than diastolic filling sounds
  • triphasic or biphasic
  • can come and go, very in intensity
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17
Q

when is it best to hear the pericardial friction rub?

A

diaphragm over left sternal border

-patient sitting upright or leaning forward

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18
Q

evaluation for acute pericarditis

A 
ESR, CBC, blood chemistries
-CXR usually normal
echo
viral studies
autoimmune serologies
pericardiocentesis if suspect purulent pericarditis, malignancy or large effusion
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19
Q

evaluation for acute pericarditis

A
  • history, ECG, exam
  • ESR, CBC, blood chemistries
  • CXR usually normal
  • echo
  • viral studies
  • autoimmune serologies
  • pericardiocentesis if suspect purulent pericarditis, malignancy or large effusion
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20
Q

what is seen on ECG with acute pericarditis

A

seen with visceral inflammation of pericardium
ST and PR segment change:
-convex shape for ST segment
-diffuse ST elevation (acute pericarditis): I, II, III, aVF, V2-6
-PR depression: II, III, aVF
-aVR ST depressions
-aVR PR segment elevation

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21
Q

what is important to do on physical exam for chest pain

A
  • ask where it hurts

- press on the spot-> to see if its musculoskeletal

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22
Q

ECG stages in pericarditis: Stage 1

A

first hours to days

-ST elevation and PR depression

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23
Q

ECG stages in pericarditis: Stage 2

A

first week

normalization of ST and PR segment

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24
Q

ECG stages in pericarditis: Stage 3

A

T wave inversions, AFTER ST have become isoelectrical

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25
Q

ECG stages in pericarditis: Stage 4

A

hjj

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26
Q

complications of acute pericarditis

A
  1. pericardial effusion and tamponade
  2. constrictive pericarditis (late)
  3. relapse
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27
Q

early repolarization will be seen in

A

I, aVL, V4-6

-ST elevation seen more in V4-6

28
Q

acute pericarditis ECG summary

A
  • sinus tachycardia
  • diffuse concave ST elevations
  • PR segment depression
  • PR elevation and ST depression in aVR
29
Q

medical therapy for viral or idiopathic pericarditis

A

-combination of NSAID’s and colchicine (3 months)
-NSAIDs (high dose)
indomethacin, ibuprofen
-for 2 weeks

30
Q

pericarditis post Acute MI

A

aspirin and colchicine

avoid NSAIDs, interfere with healing and scar formation

31
Q

colchicine

A

take for 3 months

  • 8% diarrhea
  • metabolized by CYP, watch for drug interactions
  • not good with severe renal or liver disease, blood dyscrasias or GI motility disorders
32
Q

watch giving NSAID’s because

A

renal insufficiency
administer with food
Proton pump inhibitor with long term use

33
Q

glucocorticoids

A
  • patients with symptoms refractory to standard therapy
  • acute pericarditis due to connective tissue disease
  • uremic pericarditis
34
Q

treatment for acute pericarditis

A

high dose aspirin
NSAIDs
steroids
colchicine
intensified hemodyalsis for uremic pericarditis
pericardiocentresis for tamponade or purulent

35
Q

pericardial effusion

A

accumulation of fluid in pericardial space

pushes on heart and creates tamponade

36
Q

causes of pericardial effusion

A 
acute pericarditis
radiation
malignancy
cardiac perforation
hypothyroidism
connective tissue disease
post-myocardial
chronic renal failure
aortic dissection
37
Q

what seen on ECG for pericardial tamponade

A
  • tachycarida
  • low QRS voltage in all leads-> small amplitudes
  • see electrical alternans
38
Q

what do you see on ECG with pericardial effusion (tamponade)?

A

-electrical alternans

39
Q

pathophysiology of pericardial tamponade

A
  • pericardial fluid increases intrapericardial pressure
  • increased intrapericardical pressure impedes diastolic filling LV and RV
  • RV and LV diastolic pressure rises
  • stroke volume decreases
  • cardiac output decrease
  • systemic BP drops, pulse pressure narrows, and heart rate increases
40
Q

presentation pericardial tamponade

A
  • depends on chronicity of process
  • CHF symptoms with clear lungs
  • unexplained signs of right jugular heart failure: edema and increased JVP
  • new cardiomegaly on CXR
  • sinus tachycardia, low voltage, electrical alternans on ECG
41
Q

what is pulse paradoxus

A

-exaggerated drop in systemic blood pressure during inspiration is termed pulsus paradoxus

42
Q

pulsus paradoxus

A
  • systemic arterial pressure normally falls by less than 10 mmHg during inspiration
  • fall of systolic blood pressure of >10mmHg with inspiration
43
Q

in pulsus paradoxus, on inspiration

A

the LV gets compressed

44
Q

in pulsus paradoxus, on expiration

A

the LV expands

45
Q

physical findings of pericardial tamponade

A 
sinus tachycardia
tachypnea
hypotension (late) with narrow pulse pressure
elevated JVP with loss of Y descent 
edema
pulsus paradoxus
46
Q

mechanism of pulsus paradoxus in tamponade

A

increased ventricular interdependence
Normally: inspiration increases venous inflow to the RV, RV free wall expands

In tamponade: Inspiration increases venous inflow to the RV, RV free wall cannot expand

  • diminished stroke volume with inspiration
  • inspiratory increase in venous return–> causing septal shift imprinting on LV volume
47
Q

evaluation of pericardial tamponade

A 
history and exam
ECG, CXR
emergent echo with doppler
right heart catheterization 
pericadriocentesis
48
Q

pericardial tamponade treatment

A 
medical emergency 
pericadriocentesis
IVF
vasopressors as needed
pericardial window 
Prompt pericardiocentesis
49
Q

what to avoid in pericardial tamponade

A

diuretics, vasodilators, etc.

50
Q

what would be in pericardial analysis of fluid?

A

gram stain and bacterial and fungal culture
cytology
AFB stain and mycobacterial culture along with adenosine deaminase, interferon-gamma or lysosome (for TB)
PCR
protein, LDH, glucose, RBC, WBC

51
Q

labs for pericardial tamponade

A 
cardiac enzymes 
inflammation markers (C-reactive proteins, ESR, WBC)
thyroid function
renal function studies
body fluid cultures 
TB skin test
52
Q

constrictive pericarditis etiology

A 
idiopathic viral
post cardiac surgery
radiation therapy
connective tissue disease
post TB, bacterial
miscellaneous
53
Q

pathophysiology of constrictive pericarditis

A

chronic thickening/scarring of pericardium leads to encasement of heart and impaired diastolic filling of LV and RV

  • early diastolic filing unimpaired
  • chambers expand and collide with unyielding pericardium which halts further diastolic filling
  • dip and plateau or square root sign
54
Q

clinical presentation constrictive pericarditis

A

slow, indolent process
unexplained right heart failure: systemic congestion, fatigue, dyspnea
Often misdiagnosed as cirrhosis

55
Q

what is constrictive pericarditis misdiagnosed for?

A

cirrhosis

56
Q

unexplained right heart failure with constrictive pericarditis involves?

A

systemic congestion: edema, ascites, hepatomegaly
fatigue
dyspnea

57
Q

physical findings of constrictive pericarditis

A

elevated JVP with prominent X and Y descents
Kussmaul’s sign
pericardial knock
systemic congestion (hepatomegaly, ascites, edema)

58
Q

what is Kussmaul’s sign?

A

paradoxical rise in jugular venous pressure (JVP) on inspiration
-lack of inspiratory decline in JVP

59
Q

difference between tamponade and constrictive jugular venous pattern?

A

tamponade: loss of Y descent
constrictive: X and Y descent

60
Q

where would the pericardial knock in constrictive pericarditis be present on ECG?

A

after T wave

LA

61
Q

evaluation of constrictive pericarditis

A 
history and exam
ECG: low voltage, ST&T wave changes 
CXR: pericardial calcifications
chest CT: pericardial thickening 
cardiac MRI
echo
simultaneous right and left heart hemodynamics
62
Q

what is seen on CXR, that is HALLMARK for constrictive pericarditis

A

pericardial calcification

-from chronic pericarditis

63
Q

what is seen on ECG for constrictive pericarditis

A

low voltage, ST and T wave changes

64
Q

what is seen on chest CT for constrictive pericarditis

A

pericardial thickening

65
Q

what is meant with simultaneous right and left heart hemodynamics in constrictive pericarditis?

A

equalization of LV and RV diastolic pressure

66
Q

therapy for constrictive pericarditis?

A

diuretics

pericardial stripping

icm-cardio (21 decks)

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