Pericardial disease Flashcards
pericardium
visceral and parietal layer with pericardial cavity between them
how much fluid is in the pericardium?
15-50ml
pericarditis
inflammation of pericardium
- acute and recurrent pericarditis
- pericaridal effusion without major hemodynamic compromise
- cardiac tamponade
- constrictive pericarditis
acute pericarditis
rapidly inflammation of pericardium
causes of pericarditis
radiation neoplasms: primary, metastatic, or paraneoplastic trauma autoimmune metabolic: hypothyroidism, uremia
infection causes
viral
Bacterial:
fungal:
AIDS
infection causes: viral
coxsackie, echovirus, mumps, adeno, HIV
bacterial causes
TB, pneuomococcus, strept, staph, legionella
infection causes: fungal
histoplasmosis, coccidioidomycosis, candida, blastomycosis
cardiac causes of pericarditis
- early infarction
- late post cardiac injury (Dressler’s)
- myocarditis
- resulting from dissecting aortic aneurysm
drugs that cause pericarditis
procainamide
isoniazide
hydralazine
etiology of acute pericarditis
most idiopathic vial neoplastic TB/histoplasmosis radiation purulent (bacterial) connective tissue disease post-myocardial infarction uremia
pathological anatomy of acute pericarditis
- usually fluid accumulation
- bacterial or tumor
- sometimes bacterial infection causes purulent pericarditis
- fluid may resolve or form adhesions
chest pain
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
presentation of acute pericarditis
chest pain (unrelated to exertion)
fatigue, dyspnea, malaise
fever
-can mimic onset of the flu
what causes the pericardial friction rub
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
when is it best to hear the pericardial friction rub?
diaphragm over left sternal border
-patient sitting upright or leaning forward
evaluation for acute pericarditis
ESR, CBC, blood chemistries -CXR usually normal echo viral studies autoimmune serologies pericardiocentesis if suspect purulent pericarditis, malignancy or large effusion
evaluation for acute pericarditis
- history, ECG, exam
- ESR, CBC, blood chemistries
- CXR usually normal
- echo
- viral studies
- autoimmune serologies
- pericardiocentesis if suspect purulent pericarditis, malignancy or large effusion
what is seen on ECG with acute pericarditis
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
what is important to do on physical exam for chest pain
- ask where it hurts
- press on the spot-> to see if its musculoskeletal
ECG stages in pericarditis: Stage 1
first hours to days
-ST elevation and PR depression
ECG stages in pericarditis: Stage 2
first week
normalization of ST and PR segment
ECG stages in pericarditis: Stage 3
T wave inversions, AFTER ST have become isoelectrical
ECG stages in pericarditis: Stage 4
hjj
complications of acute pericarditis
- pericardial effusion and tamponade
- constrictive pericarditis (late)
- relapse
early repolarization will be seen in
I, aVL, V4-6
-ST elevation seen more in V4-6
acute pericarditis ECG summary
- sinus tachycardia
- diffuse concave ST elevations
- PR segment depression
- PR elevation and ST depression in aVR
medical therapy for viral or idiopathic pericarditis
-combination of NSAID’s and colchicine (3 months)
-NSAIDs (high dose)
indomethacin, ibuprofen
-for 2 weeks
pericarditis post Acute MI
aspirin and colchicine
avoid NSAIDs, interfere with healing and scar formation
colchicine
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
watch giving NSAID’s because
renal insufficiency
administer with food
Proton pump inhibitor with long term use
glucocorticoids
- patients with symptoms refractory to standard therapy
- acute pericarditis due to connective tissue disease
- uremic pericarditis
treatment for acute pericarditis
high dose aspirin
NSAIDs
steroids
colchicine
intensified hemodyalsis for uremic pericarditis
pericardiocentresis for tamponade or purulent
pericardial effusion
accumulation of fluid in pericardial space
pushes on heart and creates tamponade
causes of pericardial effusion
acute pericarditis radiation malignancy cardiac perforation hypothyroidism connective tissue disease post-myocardial chronic renal failure aortic dissection
what seen on ECG for pericardial tamponade
- tachycarida
- low QRS voltage in all leads-> small amplitudes
- see electrical alternans
what do you see on ECG with pericardial effusion (tamponade)?
-electrical alternans
pathophysiology of pericardial tamponade
- 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
presentation pericardial tamponade
- 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
what is pulse paradoxus
-exaggerated drop in systemic blood pressure during inspiration is termed pulsus paradoxus
pulsus paradoxus
- systemic arterial pressure normally falls by less than 10 mmHg during inspiration
- fall of systolic blood pressure of >10mmHg with inspiration
in pulsus paradoxus, on inspiration
the LV gets compressed
in pulsus paradoxus, on expiration
the LV expands
physical findings of pericardial tamponade
sinus tachycardia tachypnea hypotension (late) with narrow pulse pressure elevated JVP with loss of Y descent edema pulsus paradoxus
mechanism of pulsus paradoxus in tamponade
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
evaluation of pericardial tamponade
history and exam ECG, CXR emergent echo with doppler right heart catheterization pericadriocentesis
pericardial tamponade treatment
medical emergency pericadriocentesis IVF vasopressors as needed pericardial window Prompt pericardiocentesis
what to avoid in pericardial tamponade
diuretics, vasodilators, etc.
what would be in pericardial analysis of fluid?
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
labs for pericardial tamponade
cardiac enzymes inflammation markers (C-reactive proteins, ESR, WBC) thyroid function renal function studies body fluid cultures TB skin test
constrictive pericarditis etiology
idiopathic viral post cardiac surgery radiation therapy connective tissue disease post TB, bacterial miscellaneous
pathophysiology of constrictive pericarditis
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
clinical presentation constrictive pericarditis
slow, indolent process
unexplained right heart failure: systemic congestion, fatigue, dyspnea
Often misdiagnosed as cirrhosis
what is constrictive pericarditis misdiagnosed for?
cirrhosis
unexplained right heart failure with constrictive pericarditis involves?
systemic congestion: edema, ascites, hepatomegaly
fatigue
dyspnea
physical findings of constrictive pericarditis
elevated JVP with prominent X and Y descents
Kussmaul’s sign
pericardial knock
systemic congestion (hepatomegaly, ascites, edema)
what is Kussmaul’s sign?
paradoxical rise in jugular venous pressure (JVP) on inspiration
-lack of inspiratory decline in JVP
difference between tamponade and constrictive jugular venous pattern?
tamponade: loss of Y descent
constrictive: X and Y descent
where would the pericardial knock in constrictive pericarditis be present on ECG?
after T wave
LA
evaluation of constrictive pericarditis
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
what is seen on CXR, that is HALLMARK for constrictive pericarditis
pericardial calcification
-from chronic pericarditis
what is seen on ECG for constrictive pericarditis
low voltage, ST and T wave changes
what is seen on chest CT for constrictive pericarditis
pericardial thickening
what is meant with simultaneous right and left heart hemodynamics in constrictive pericarditis?
equalization of LV and RV diastolic pressure
therapy for constrictive pericarditis?
diuretics
pericardial stripping
