Pericardial Disease

Question 1

A 30 year old male from Uganda (region has nothing to do with pathology here, just a mnemonic), Victa Umat, comes in to the ER with sudden onset of severe chest pain. He comments that the pain varies with laying down or standing up and breathing. This is a common presentation for:

Answer 1

Acute Pericarditis

Question 2

You tell Victa Umat that acute pericarditis is most commonly caused caused by:

Answer 2

• *1. Viral illness
  2. Connective tissue or autoimmune diseases 3. Uremia
  4. Metastatic tumors

Notice the mnemonic in the name Vi, CT A, U, MT

Question 3

You assure Victa that you will perform all the necessary exams to diagnose his Acute pericarditis. You begin with a cardiac exam and notice that he has a ____________ when you auscultated his apex of the heart.

Answer 3

Pericardial (friction) Rub.

Question 4

After hearing Victa’s pericardial rub, you decide to further test for Acute pericarditis by ordering 2 other studies. Which studies do you order and what do you expect to see?

Answer 4

EKG- Diffuse ST elevation
(means the injury involves most of the heart. Seen across many of the leads on an EKG.)

ECHO- Pericardial fluid.

Question 5

Victa’s EKG and ECHO come back as expected, with diffuse ST elevation and pericardial fluid. You inform him of his diagnosis of Acute pericarditis and tell him that you will prescribe __________ medications to help him.

Answer 5

Anti Inflammatory medications:

Ibuprofen

• Asprin
• *Colchicine (reduces recurrent events)

Question 6

You return to your preceptor and begin to do an oral presentation of your patient. In your OP be sure to include the most common causes, presentation, diagnosis and treatment for Acute pericarditis. What do you tell him.

This is an important card that summarizes all the previous cards

Answer 6

VICTA UMAT is a 65 yo male presenting with sudden, severe chest pain that varies with position and as he breathes.

Cardiac exam revealed a Pericardial rub. EKG showed diffuse elevated ST wave and ECHO showed pericardial fluid.

My leading diagnosis is Acute Pericarditis caused by Viral illness (VICTA UMAT). I recommend that we treat him with 300-800mg of ibuprofen every 6-8 hrs.

Question 7

As you finish with Victa, his good friend Ham Va’u from Tonga comes to see you. You laugh because he is a very large man and has a “ham-like” appearance. He presents to your clinic hypotensive and with distended neck veins. You are suspicious of_________.

Answer 7

A cardiac Tamponade (aka pericardial effusion with Tamponade)

Question 8

Ham Va’u is obviously worried about his heart. He asks if a cardiac Tamponade has to do with the tampons that his wife uses. You try not to bust your gut laughing and tell him that a Tamponade is caused by pericardial effusions. Pericardial effusions may be caused by:

Answer 8

1. Hypothyroidism
2. Autoimmune dieseases
3. Metastatic malignancy
4. Viral or Acute pericarditis
5. Uremia

I’m not sure this card is super important, but it goes with the mnemonic. it is super similar to all the stuff from acute pericarditis, but with hypothyroidism as well.

Question 9

In order to correctly diagnose Ham you order 2 studies. Which studies do you order and what do you expect to find?

Answer 9

1. X-ray- Enlarged heart w/o lung congestion

2. ECHO- Large pericardial effusion

Question 10

You also observe Ham’s vitals and notice that something strange happens to his BP when he inspires. What happens and what is this called?

Answer 10

His systolic BP drops by 10mm Hg when he inspires. This is called “paradoxical pulse.”

Question 11

Why do paradoxical pulses happen?

Answer 11

Normally the right side of the heart expands during inspiration due to - thoracic pressure. In Tamponade, the heart cant expand due to the surrounding fluid.

Because it cant expand in its normal space, the right ventricle fills completely and pushes into the left heart and causes a decrease in stroke volume from the Left Ventricle- thus lowering the systolic pressure.

Question 12

You inform Ham that he does indeed have a Tamponade. You treat him by _______

Answer 12

Pericardiocentesis

IV fluids to support ventricular filling.

DO NOT use diuretics like CHF

Question 13

True or False: Pericardial effusion is usually accompanied by pleural effusion.

Answer 13

False.

Pericardial effusion is a RV disease therefore it doesn’t back up the lungs.

Question 14

Electrical Alternans may be seen in which pericardial disease? What is Electrical alternans?

Answer 14

Cardiac tamponades

Electrical alternans occurs when the heart swings from side to side. An EKG will show alternating sized QRS waves on the same lead due to the position of the heart.

Question 15

What is the basic process of constrictive pericarditis?

Answer 15

Scaring and loss of elasticity of the pericardium interferes with the diastolic function of the heart.

Leads to RHF symptoms and RHF.

Question 16

What is the most common presentation of constrictive pericarditis?

Answer 16

Post radiation (breast cancer)

Elevated Jugular VP 
Tachycardia
Hepatomegaly 
Edema
Ascities.

Question 17

How do you confirm a diagnosis of constrictive pericarditis?

Answer 17

1. Echo
2. MRI/CT
3. Cardiac Catheterization

Question 18

What would you expect to see on a cardiac cath of a patient with constrictive pericarditis?

Answer 18

1. Dip and Plateau (square root sign) during diastole

2. Elevation of RVP and depression of LVP during inspiration.