Pericardial disease Flashcards
Constrictive pericarditis
- causes
- mechanism
- clinical features
- differential diagnosis
- how do we differentiate
- tests
- treatment
- Unknown (uk),TB,following any type of pericarditis (haemopericardium,rheumatic pericarditis,viral)
- fibrosis and calcification of the pericardium–>decreased expansion of pericardium–>impaired venous return
- rise JVP,kussmul’s breathing(paradoxically increase JVP with inspiration),diffuse apex beat,quiet heart sounds,S3,diastolic pericardial knock,ascites,hepatosplenomegaly,oedema
- differentiate from cardiac temponade (JVP,pulses paradox us,kussmul’s breathing),restrictive pericarditis (CT/MRI)
- CXR:small heart+/-pericardial calcification,echo-cardiac catheterization
- treated by surgical resection
How Do you differentiate cardiac temponade from constrictive pericarditis?
JVP. Y descent absent X and Y descent
Pulses paradoxus. Specific. Less specific
Kussmul’s breathing. Rare. Present
Note:TEMponade=TEMpeX
Pericardial effusion
- causes
- clinical features
- ECG changes
- treatment
-pericarditis,myocardial rupture (haemopericardium-stab wounds,surgical,post MI),aortic dissection,pericardium filling with pus,malignancy
-dyspnoea,raised JVP(prominent X descent),bronchial breathing at left base (Ewart’s sign:left effusion compressing left lower lobe),hiccough (phrenic nerve),nause (diaphragm),muffled heart sounds
-Diagnosis:CXR-enlarged globular heart if effusion>300ml,ECG-low voltage QRS complexes,electrical alternans,echo-echo free zone around heart
-pericardiocentasis (therapeutic/diagnostic)-culture,cytology
-
What are the treatment for different types of pericarditis?
Pericarditis-Ibuprofen Recent MI-Aspirin Rheumatic fever-Aspirin Dressler's syndrome (post MI)-steroids Recurrence-Colchicine
Cardiac Temponade
- mechanism
- clinical features
- differential diagnosis
- how do we differentiate
- tests
- treatment
Fatal*
- pericardial effusion that raises intrapericardial pressure,reducing ventricular filling and reducing CO
- diagnostic:Beck’s triad-raised JVP,fallin pressure,muffled heart sounds,(refer pericardial effusion)
Acute Pericarditis
- clinical features
- Test
- central chest pain worsening on inspiration or lying flat,relieved by sitting forward.pericardial friction rub,+/-fever,+/-pericardial effusion/cardiac temponade
- ECG : conceived (saddle shaped)ST elevation , PR depression,T inversion (D/D:MI-no q wave)
- cardiac enzymes may be raised
- CXR:cardiomegaly may indicate paricardial effusion–>echo
Cause include hypothyroidism
Jugular venous examination finding in cardiac temponade
Blunted or absent y descent
TEMponade=TEMpaX
Harmodynamic finding in cardiac temponade
Equalization of LV and RV pressure (cardiac catheterization)
If patient has CA breast,what cardiac issues should you think of?
Cardiomegaly,Constrictive pericarditis or temponade
Where can pericarditis pain radiate to?
Trapezius
What is the yield of serological studies in acute pericarditis?
Low
COPE trial result for acute pericarditis
Colchicine reduce recurrent rate vs placebo
2 side effects of colchicine
Diarrhea
Bone marrow depression
Can colchicine be given in renal or hepatic dysfunction?
No
In what cases are colchicine side effects pronounced?
Interaction with CYP3A4 drug (CCB,Amino,Cyclosporine)
What do you see on mitral and tricuspid inflow velocities on Echo (E wave) in constrictive pericarditis?
Respiratory flow variation
On echo in constrictive pericarditis,what is the septum doing?
Diastolic bounce
What do the atria look like on echo in constrictive pericarditis?
Dilated despite TR/MR
What is a normal pericardial thickness?
What is the abnormal pericardial thickness?
2 mm
> 4mm
Ventricular interdependence
Constrictive pericarditis
What is the PASP usually in constrictive pericarditis? Restrictive pericarditis?
(PASP=pulmonary arterial systolic pressure)
Constrictive <50
Restrictive >80
The number one reason to suspect constriction
LV/RV interdependence
What pattern will MV inflow have on echo in constrictive pericarditis?
Restrictive pattern
3 factors that deme a worse prognosis s/p pericardiectomy for constriction?
Age, NYHA class,post radiation as cause
First line agents to treat acute pericarditis
NSAIDS (GI cover), Colchicine
Diagnostic criteria for post pericardiotomy syndrome
2 of the following: Pleuritic chest pain Friction rub Pleural effusion New or worsening pericardial effusion Fever >1 week post op
Definition of myoperucarditis
Elevation of cardiac enzymes or new LV dysfunction
What population is more prone to get myopericarditis?
Male age<40
Definition of pulses paradoxus (temponade)
Inspiratory decrease in SBP>10
What causes false positive result for pulsus paradoxus,making you think that there is temponade?
COPD,PE,Constrictive pericarditis
P * 3
What causes false negative to constrictive pericarditis?
LVH,AI,ASD,VENTricular localized effusion,severe hypotension
Treatment t of temponade
IVF,I tropes/vasopressors if hypotension persists, pericardiocentasis,avoid vent
What is appearance of Y descent in constrictive pericarditis?
Prominent
Increased RAP,prominent Y descent,tachycardia
Most likely diagnosis?
Constrictive pericarditis
Description of constrictive pericarditis
Obliterated pericardial space and adhesive pericarditis
What sxs will patient get in constrictive pericarditis is RA=LA are 10 mmHg?
Hepatosplenomegaly, oedema
What sxs will patient get in constrictive pericarditis is RA=LA are >18 mmHg?
Dyspnoea,orthophosphate
What stage of cardiac cycle do restrictive and constrictive CM affect mainly?
Diastole
What is the systolic function (usually)in restrictive and constrictive pericarditis?
Normal
What is the kussmaul’s sign?
Elevated JVP on inspiration
Seen in constrictive pericarditis
What is friedrich’s sign and what dz state it is seen in?
Prominen Y descent
Constrictive pericarditis
