Pericardial disease

Question 1

Constrictive pericarditis

• causes
• mechanism
• clinical features
• differential diagnosis
• how do we differentiate
• tests
• treatment

Answer 1

• 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

Question 2

How Do you differentiate cardiac temponade from constrictive pericarditis?

Answer 2

JVP. Y descent absent X and Y descent
Pulses paradoxus. Specific. Less specific
Kussmul’s breathing. Rare. Present

Note:TEMponade=TEMpeX

Question 3

Pericardial effusion

• causes
• clinical features
• ECG changes
• treatment

Answer 3

-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
-

Question 4

What are the treatment for different types of pericarditis?

Answer 4

Pericarditis-Ibuprofen
Recent MI-Aspirin
Rheumatic fever-Aspirin
Dressler's syndrome (post MI)-steroids
Recurrence-Colchicine

Question 5

Cardiac Temponade

• mechanism
• clinical features
• differential diagnosis
• how do we differentiate
• tests
• treatment

Answer 5

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)

Question 6

Acute Pericarditis

• clinical features
• Test

Answer 6

• 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

Question 7

Jugular venous examination finding in cardiac temponade

Answer 7

Blunted or absent y descent

TEMponade=TEMpaX

Question 8

Harmodynamic finding in cardiac temponade

Answer 8

Equalization of LV and RV pressure (cardiac catheterization)

Question 9

If patient has CA breast,what cardiac issues should you think of?

Answer 9

Cardiomegaly,Constrictive pericarditis or temponade

Question 10

Where can pericarditis pain radiate to?

Answer 10

Trapezius

Question 11

What is the yield of serological studies in acute pericarditis?

Answer 11

Low

Question 12

COPE trial result for acute pericarditis

Answer 12

Colchicine reduce recurrent rate vs placebo

Question 13

2 side effects of colchicine

Answer 13

Diarrhea

Bone marrow depression

Question 14

Can colchicine be given in renal or hepatic dysfunction?

Answer 14

No

Question 15

In what cases are colchicine side effects pronounced?

Answer 15

Interaction with CYP3A4 drug (CCB,Amino,Cyclosporine)

Question 16

What do you see on mitral and tricuspid inflow velocities on Echo (E wave) in constrictive pericarditis?

Answer 16

Respiratory flow variation

Question 17

On echo in constrictive pericarditis,what is the septum doing?

Answer 17

Diastolic bounce

Question 18

What do the atria look like on echo in constrictive pericarditis?

Answer 18

Dilated despite TR/MR

Question 19

What is a normal pericardial thickness?

What is the abnormal pericardial thickness?

Answer 19

2 mm

> 4mm

Question 20

Ventricular interdependence

Answer 20

Constrictive pericarditis

Question 21

What is the PASP usually in constrictive pericarditis? Restrictive pericarditis?

(PASP=pulmonary arterial systolic pressure)

Answer 21

Constrictive <50

Restrictive >80

Question 22

The number one reason to suspect constriction

Answer 22

LV/RV interdependence

Question 23

What pattern will MV inflow have on echo in constrictive pericarditis?

Answer 23

Restrictive pattern

Question 24

3 factors that deme a worse prognosis s/p pericardiectomy for constriction?

Answer 24

Age, NYHA class,post radiation as cause

Question 25

First line agents to treat acute pericarditis

Answer 25

NSAIDS (GI cover), Colchicine

Question 26

Diagnostic criteria for post pericardiotomy syndrome

Answer 26

``` 2 of the following: Pleuritic chest pain Friction rub Pleural effusion New or worsening pericardial effusion Fever >1 week post op ```

Question 27

Definition of myoperucarditis

Answer 27

Elevation of cardiac enzymes or new LV dysfunction

Question 28

What population is more prone to get myopericarditis?

Answer 28

Male age<40

Question 29

Definition of pulses paradoxus (temponade)

Answer 29

Inspiratory decrease in SBP>10

Question 30

What causes false positive result for pulsus paradoxus,making you think that there is temponade?

Answer 30

COPD,PE,Constrictive pericarditis P * 3

Question 31

What causes false negative to constrictive pericarditis?

Answer 31

LVH,AI,ASD,VENTricular localized effusion,severe hypotension

Question 32

Treatment t of temponade

Answer 32

IVF,I tropes/vasopressors if hypotension persists, pericardiocentasis,avoid vent

Question 33

What is appearance of Y descent in constrictive pericarditis?

Answer 33

Prominent

Question 34

Increased RAP,prominent Y descent,tachycardia | Most likely diagnosis?

Answer 34

Constrictive pericarditis

Question 35

Description of constrictive pericarditis

Answer 35

Obliterated pericardial space and adhesive pericarditis

Question 36

What sxs will patient get in constrictive pericarditis is RA=LA are 10 mmHg?

Answer 36

Hepatosplenomegaly, oedema

Question 37

What sxs will patient get in constrictive pericarditis is RA=LA are >18 mmHg?

Answer 37

Dyspnoea,orthophosphate

Question 38

What stage of cardiac cycle do restrictive and constrictive CM affect mainly?

Answer 38

Diastole

Question 39

What is the systolic function (usually)in restrictive and constrictive pericarditis?

Answer 39

Normal

Question 40

What is the kussmaul's sign?

Answer 40

Elevated JVP on inspiration | Seen in constrictive pericarditis

Question 41

What is friedrich's sign and what dz state it is seen in?

Answer 41

Prominen Y descent | Constrictive pericarditis