Pericardial Disease Flashcards
What are the two layers of the pericardium?
Visceral pericardium - inner serosal layer
Parietal pericardium - outer fibrous layer
What happens to the intrapericardial pressure (i.e. the pressure on fluid in pericardium) with breathing?
Negative pressure on inspiration
Positive pressure on expiration
But normally should only vary +/- 5 mm Hg
What is the definition of pericarditis?
Inflammation of pericardium
What are the two types of causes of acute pericarditis and which is more common?
Infectious - more common
Non-infectious
What type of infections cause acute pericarditis and which is more common?
Viral - more common
TB
Pyogenic bacteria
Which viruses typically cause viral (“idiopathic”) pericarditis?
Echovirus
Coxsackie B
Is it helpful to get viral titers of someone with acute pericarditis?
No
By the time results are available, symptoms have abated
How does acute pericarditis appear?
Serofibrinous pericarditis - plasma proteins like fibrinogen, rough & shaggy, red and inflammed
“Bread and butter”
What are clinical features of acute pericarditis?
Pleuritic chest pain - relieved by leaning forward, sitting up
Fever
Pericardial friction rub - 3 components
EKG abnormalities
Describe the pericardial friction rub that occurs in acute pericarditis
Will have scratching sounds when ventricles contract and relax, and when atria contract (3 components)
Sounds like creaking leather
Describe the EKG abnormalities that occur in acute pericarditis
DIFFUSE ST elevation in all leads
PR depression - subtle, diagnostic of pericarditis
What is the treatment for acute pericarditis?
Self limiting - only need bed rest and NSAIDs
AVOID anticoagulants - will bleed into pericardium
What organisms will cause purulent pericarditis?
Staph and other gram negative rods
How does purulent pericarditis appear?
Intense inflammatory response
Serosa is erythematous and coated with purulent exudate
How does hemorrhagic pericarditis appear?
Gross blood in pericardium
Usually due to trauma, TB, or cancer
What is the treatment for purulent pericarditis?
Catheter drainage
Antibiotics
Mortality very high
What is the treatment for TB pericarditis?
Anti-TB meds
What are possible non-infectious causes of pericarditis?
Post MI Uremia Cancer Radiation induced Connective-tissue disease Drug-induced
What are the two forms of post MI pericarditis?
Early form - hear rub in 10-15% of STEMI patients
Late form - Dressler’s syndrome
Hear rub 2 weeks-several months after STEMI, possible autoimmune related
Which cancers typically can cause non-infectious pericarditis?
Lung
Lymphoma
Breast
Which connective-tissue disorders can cause non-infectious pericarditis?
Lupus
Rheumatoid arthritis
Which drugs can cause non-infectious pericarditis?
Procainamide
Hydralazine
What volume of pericardial fluid qualifies as pericardial effusion?
> 50 cc
What are characteristics of transudate?
Clear fluid
Low protein content
Filtrate across vascular wall
Non-inflammatory
What are characteristics of exudate?
Increased vascular permeability
High protein content
Fibrous, bloody, or pus
Infection, cancer, collagen vascular
What are the three major organs/organ systems that cause transudates?
Heart failure (CHF) Liver failure (cirrhosis) Renal failure (nephrotic syndrome)
What is a hemopericardium effusion?
Free blood in the effusion
= rupture
What is a chylopericardium effusion?
Free chyle (milky) in the effusion = lymphatic obstruction by cancer, inflammation, injury to lymphatics
What are the symptoms of pericardial effusion?
NONE - asymptomatic
What are clinical features of a pericardial effusion?
Reduced heart sounds
Inability to feel apical beat
Ewart’s sign - dullness over posterior lung
But these can be absent if effusion isn’t very large
What is the most useful tool to diagnose a pericardial effusion?
Echocardiogram
What is the definition of cardiac tamponade?
Hemodynamic abnormalities that result from accumulation of pericardial effusion UNDER PRESSURE
What occurs to the diastolic pressures (“filling pressures”) when there is tamponade?
Equalization of all filling pressures
Diastolic pressures can not be less than the pericardial pressure that is compressing them
What are the hemodynamic consequences of an equalization of filling pressures in tamponade?
Equalization of pressures –> decrease in filling of ventricles –> SV decreases –> CO decreases –> hypotension, shock, death
What is the most important factor in determining how high the pressure gets in the pericardium?
Rate of accumulation
i.e. get tamponade acutely from hemorrhage, pressure will skyrocket quickly
What are causes of tamponade?
Anything that causes acute pericarditis Cancer Uremia Post viral Hemorrhage
What is the classic triad of clinical signs of tamponade?
Beck’s triad
Increased venous pressure
Hypotension (from the decreased CO)
Diminished heart sounds
What is the most important physical finding in tamponade?
Pulsus paradoxus
Describe the phenomenon of pulsus paradoxus
Decrease in systolic BP > 10 mm Hg during NORMAL inspiration
When you inspire, lungs take up a little more blood, so have slightly less blood returning to LA. In normal people, this only changes BP by ~1-2 mm Hg. In tamponade, this is >10 mm Hg.
What are clues to tamponade on echocardiogram?
Pericardial effusion (can’t have tamponade without effusion!)
RA collapse
RV collapse
Dilated IVC (backup of blood since chambers can’t expand)
What are clues to tamponade on EKG?
Electrical alternans (amplitude of QRS varies from beat to beat)
Due to movement of effusion fluid
What is the definitive test to define tamponade that is done in the cath lab?
Measure diastolic pressures of all chambers
Equalization of diastolic pressures = tamponade
How do you treat cardiac tamponade?
Pericardiocentesis - stick needle in, extract fluid
Pericardial window - cut window for fluid to exit
Pericardiotomy - remove entire pericardium
What is constrictive pericarditis?
“Egg shell disease”
Thick and stiff pericardium around the heart
What are causes of constrictive pericarditis?
TB
Surgery - bleeding in pericardium can scar over time and become stiff
Radiation
What other pathology can constrictive pericarditis look like and how could you differentiate?
Appears like tamponade Be suspicious if patient exhibits: - Heart failure - Liver cirrhosis - Intra-abdominal tumor
What are clues of constrictive pericarditis on physical exam?
Pericardial knock
Prominent “y” descent in jugular vein
Kussmaul’s sign
On a chest xray, what is diagnostic of constrictive pericarditis?
Pericardial calcification
Looks like an egg shell around heart
What are clues of constrictive pericarditis on pressure curve?
Square root sign - “dip and plateau”
Heart can only dilate through first third of diastole, but ‘egg shell’ stops it from dilating through the rest of diastole
This is what causes the pericardial knock heard
How do you treat constrictive pericarditis?
Surgery
