Pericardial Disease

Question 1

Layers of pericardium

Answer 1

Fibrous pericardium, serous parietal, and serous visceral

Question 2

Normal amount of pericardial fluid

Answer 2

5-10 ml

Question 3

What is the most common disorder involving the pericardium?

Answer 3

Acute pericarditis- inflammation of the pericardial sac

Question 4

Acute pericarditis causes

Answer 4

Infection, autoimmune, CT disease, Neoplasms, radiation, chemo, cardiac surgery, post MI

Question 5

Example of post-MI pericarditis

Answer 5

Acute pericarditis, Dressler’s syndrome- acute illness occurring weeks to months after an MI

Question 6

Major clinical manifestation of acute pericarditis

Answer 6

Pleuritic Chest pain- sharp and pleuritic, often sudden in onset and over anterior chest, also pericardial friction rub

Question 7

What would you suspect if you heard superficial scratchy or squeaking sound with diaphragm over Left sternal border

Answer 7

Pericardial friction rub- a major characteristic of acute pericarditis

Question 8

Male patient 40 years old presents with pleuritic chest pain, described as sharp and sudden.” With stethoscope, you hear a squeaking sound over the left sternal border. Cardiac biomarkers are elevated, including troponin I and T. ECG shows ST elevation and PR depression. CXR and Echocardiography are normal. You check WBC, ESR, and Serum C-reactive protein, tuberculin test, and antinuclear antibody titer. What do you suspect?

Answer 8

Acute pericarditis

Question 9

When would echocardiography not be normal in acute pericarditis?

Answer 9

if associated pericardial effusion. Definitely order if cardiac tamponade suspected

Question 10

What organism is most often responsible for bacterial pericarditis?

Answer 10

Staph aureus

Question 11

You suspect acute pericarditis in patient but are unsure of whether it is bacterial or viral. Why is it important to differentiate?

Answer 11

Affects treatment options. Viral usually resolves within 1 month with bed rest and analgesics. Bacterial pericarditis- requires decompression of the pericardial space, IV Abx therapy for 1 month, supportive therapy

Question 12

Why should hemorrhagic pericarditis with effusion accumulation secondary to trauma be drained?

Answer 12

Because of risk of subsequent development of constrictive pericarditis

Question 13

Different types of recurrent pericarditis include

Answer 13

Rheumatolic, Uremic pericarditis, neoplastic pericarditis

Question 14

Rheumatologic pericarditis tx

Answer 14

corticosteroids and/or salicylates

Question 15

Urmic pericarditis tx

Answer 15

dialysis, pericardiotomy

Question 16

Neoplastic pericarditis tx

Answer 16

Treat primary disease, pericardiocentesis if indicated

Question 17

Type of fluid in pericardial effusion

Answer 17

Serous fluid, serosanguinous fluid, blood, pus, chyle

Question 18

Patient presents with persistent pain in chest. He had viral pericarditis 1 month ago which seems to have resolved. You hear muffled heart sounds and dullness and decreased breath sounds over L posterior lung (Ewart’s sign). You suspect…

Answer 18

Pericardial effusion

Question 19

What is Ewart’s sign and what is it associated with?

Answer 19

Dullness and decreased breath sounds over posterior L lung due to compression by large pericardial sac- seen in pericardial effusion

Question 20

Diagnosis of pericardial effusion

Answer 20

History, PE, ECG, CXR. Very similar to pericarditis. Cardiomegaly may occur due to pericardial effusion.

Question 21

Patient presents with dyspnea, fatigue, cough, and shock. PE shows pulsus paradoxus. ECG- electrical alternans. Beck’s triad also present. Diagnosis?

Answer 21

Cardiac Tamponade

Question 22

Beck’s triad

Answer 22

Elevated venous pressure, hypotension, quiet heart- seen in cardiac tamponade

Question 23

Pulsus paradoxus

Answer 23

exaggerated drop in SBP with inspiration

Question 24

Tx of cardiac tamponade

Answer 24

pericardiocentesis, pericardial window

Question 25

Tx of constrictive pericarditis

Answer 25

Pericardiectomy

Question 26

Patient presents with Kussmaul’s sign, dyspnea, ascites, edema, and pericardial KNOCK. Diagnosis and what do you suspect?

Answer 26

Suspect constrictive pericarditis. Xray- calcified pericardium. CT scan, MRI- thickened pericardium. Pericardial biopsy, cardiac cathetirization- restricted filling pattern in RV

Question 27

Pericardial KNOCK

Answer 27

Abrupt cessation of early diastolic inflow. often best heart during inspiration.

Question 28

What is classic in constrictive pericarditis

Answer 28

Pericardial Knock

Question 29

What type of pericarditis is very similar to Restrcitive cardiomyopathy?

Answer 29

Constrictive pericarditis

Question 30

Abnormal diastolic filling pattern in both constrictive pericarditis and cardiac tamponade. Reasons..

Answer 30

Cardiac tamponade- increased accumulation of fluid in pericardial sac causes increased intra-pericardial pressure which causes less diastolic filling. In constrictive pericarditis, pericardium becomes fibrous, thickened so ventricles are unable to open up as much

Question 31

Tx of constrictive pericarditis vs. cardiac tamponade

Answer 31

constrictive pericarditis- pericardioectomy. cardiac tamponade- pericardiocentesis, pericardial window

Question 32

Patient just had a MI. Is now experiencing pericardial friction rub, pleuritic pain, fever. What do you suspect?

Answer 32

Dressler’s syndrome (Post-MI pericarditis)

Question 33

You are trying to figure out if patients sharp chest pain is due to pericarditis. What do you ask them?

Answer 33

Does you pain improve when you sit up and lean forward? Does it improve upon inspiration? If yes, then diagnosis more favored.