Pericardial Disease Flashcards
What are the three main pericardial diseases?
1) Pericarditis
2) Tamponade
3) Constrictive pericarditis
What is the pericardium?
Fibroelastic sac which surrounds the heart with two serosal layers separated by a pericardial cavity, and a fibrous layer
What does the serosal layers of pericardium attach to?
Visceral attached to epicardium
Parietal attached to fibrous pericardium
T or F: pericardial pressure is less than RA
T
Whats the function of pericardium?
Restraining effect on the heart:
Prevents acute dilatation
Diastolic coupling of the ventricles
May prevent spread of infection
What are some causes of acute pericarditis?
Infections
Viral, bacterial, tuberculosis
Vasculitis/collagen vascular disease (auto-immune problems)
Rheumatoid arthritis, lupus erythematosus
Inflammatory response to injury of contiguous structures
Myocardial infarction, post-cardiac surgery
Renal failure
Trauma
What is the clinical presentation of pericarditis?
- Sharp retrosternal chest pain aggravated by inspiration and lying down
- Radiates to shoulders
- Patient feels best sitting up, leaning forward
- Dyspnea—unable to take a deep breath in
What might be some physical exam findings of pericarditis?
Low grade fever
Sinus tachycardia
Pericardial friction rub –biphasic/triphasic
Normal JVP
What ECG features are in pericarditis?
Diffuse ST elevation and PR depression (associated epicarditis)
Cardiac biomarkers (troponin) may be elevated if associated myocarditis
T or F: pericardial effusion is necessary for diagnosis of pericarditis?
Pericardial effusion may be present—but not necessary for diagnosis of pericarditis
How many features need to be present and what are they for pericarditis?
Pleuritic chest pain
Pericardial friction rub
Diffuse ST elevation on ECG
Pericardial effusion on echocardiogram
Whats the management for pericarditis?
Usually Self-limited
No strenuous physical activity until symptoms resolve
No competitive sports for at least 3 months following symptom resolution
ASA 650-1000 mg TID or Non-Steroidal Anti-Inflammatory (e.g. ibuprofen 600-800 mg TID), often tapered off over 2-4 weeks
Colchicine (anti-gout drug) 0.6 mg BID for 3 months to decrease risk of recurrence
T or F: cardiac tamponade is a medical emergency
T
What is cardiac tamponade?
Build up of pericardial fluid
Fluid puts pressure on heart, restricting filling
Leading to a drop in cardiac output
What are some causes of CT?
Malignancy 30-60% Uremia 10-15% Idiopathic 5-15% Infectious 5-15% Anticoagulation 5-10%
What is the hemodynamics of tamponade?
Exponential increase pericardial pressure –> dramatic decrease in cardiac filling –> decrease in BP –> increase in heart rate
What happens to diastolic pressures in pericardial tamponade?
ALL DIASTOLIC PRESSURES EQUALIZE
LAP / RAP / LVP / RVP –> pericardial pressure (15-20 mm Hg)
What is noticed on the pressure tracings of the heart in tamponade?
LAP, and LVP are increased (shifted upwards)
why???
Accumulation of pericardial fluid impairs relaxation and filling of the ventricles, requiring a higher filling pressure.
Why is cardiac tamponade mostly a Right heart prob?
- Pericardial fluid ‘squeezes’ heart, impacting lower pressure chambers with thinner walls –> RA then RV
- As R heart ‘squeezed’, systemic venous return backs up
- ↑↑ venous pressures –> partly overcome pericardial squeeze in an attempt to restore R heart filling / output
–> i.v. fluids –> ↑ venous pressure = RAP
BUT helps cardiac output … temporarily
As pericardial pressure rises, RA collapses, RV collapses
Venous return causes interventricular septum to push toward LV, decreasing LV size and filling = decreased CO
If pericardial pressure >20-22mm Hg –> fatal compression of R heart
At 20-22mm Hg pressure, LV (LA) less likely to be collapsed but CO affected
What is a key sign of tamponade?
pulsus paradoxus
What is pulsus paradoxus?
Inspiratory decrease in systolic pressure of > 10 mmHg
BECAUSE
Inspiration increases negative intra-thoracic pressures and venous return to the right side, septum pushes into LV and cardiac output decreases, so BP decreases
True or F: LV filling and BP increases during expiration in tamponade?
T BECAUSE
increase in positive intra-thoracic pressure –>
decrease systemic venous return –> decrease tricuspid flow / RV filling
AND
decrease pulmonary venous pooling increase blood return to left heart increase mitral flow / LV filling --> septum shifts into RV increase in LV output and systemic BP
T or F: pulmonary venous flow increases during expiration
T –> because pulmonary venous system more compliant
What are signs of CT?
Pulsus paradoxus Hypotension Tachycardia High JVP Mild edema (if very chronic) Soft/muffled heart sounds
What are symptoms of CT?
Lightheaded, syncope
Dyspnea
What is a X-ray feature of cardiac tamponade?
‘flask’ or ‘bottle’-shaped heart
↑ cardiac silhouette if large pericardial effusion
What does an echicardiogram (KEY TEST) confirm in tamponade?
confirms pericardial effusion under pressure compressing cardiac chambers
What is the treatment for CT?
Removal of pericardial fluid = Pericardiocentesis
Surgical pericardial window if not accessible by needle
IV fluids –> ↑↑ venous pressure –> ↑R heart filling while waiting
Why is the y descent (passive atrial emptying) absent in tamponade?
The y descent (atrial emptying) is usually absent in tamponade because early diastolic blood flow from the right atrium to the right ventricle is impaired by the compressive effect of the surrounding pericardial fluid
What are key features of constrictive pericarditis?
Dissociation between intra-cardiac and intra-thoracic pressures
Exaggerated ventricular interaction
Hemodynamically what happens in CP?
Stiff pericardium only allows limited cardiac filling before abrupt cessation of further filling (rigid pericardial ‘box’)
increase in venous back-pressures as a result
Once pericardial limit to filling reached, ALL END DIASTOLIC PRESSURES EQUALIZE:
LAP = RAP = LVEDP = RVEDP as all equally ‘squeezed’ by pericardial box
T or F: systolic function is affected in CP
F: systolic function unaffected BUT
decrease in ventricular filling
decrease in stroke volume
increase in HR (compensatory)
T or F: there is increased LVP and LAP during diastole due to rapid filling (elevation after y descent) in CP
T
Why is there a sharp y descent in CP?
Because atria empty rapidly
What the name for the vent that occurs in early diastole where LV / RV hit rigid limit of pericardium, no longer able to fill in CP?
pericardial knock
Why is there a plateau phase instead of a gradual increase leading up to the a wave?
Abrupt cessation of atrial and ventricular filling= plateau phase
T or F : RV and LV filling happens only in early diastole even though RAP/LAP increases
True
Only filling early in diastole –> NO further ↑RV / LV filling no matter how high RAP / LAP
What is ventricular coupling?
Ventricular interdependence(or ventricular coupling) is a phenomenon whereby the function of one ventricle is altered by changes in the filling of the other ventricle. This leads to increase in volume of one ventricle associated with a decreased volume in the opposite ventricle.
What are some causes of CP?
Idiopathic Post-pericarditis Post-cardiac surgery Tuberculosis Radiation therapy for cancer Collagen vascular disease - Rheumatoid arthritis - Systemic lupus erythematosus
What are symptoms of CP?
Right heart failure with ↑↑↑ edema and ascites over months-year (↑↑ venous back pressure)
Dyspnea + fatigue with exertion (↓ cardiac output, not left heart failure, needs LA pressure > 20-25mm Hg)
No chest pain
What are some signs of CP?
↑↑ JVP with prominent x’ and y descents Kussmaul sign (inspiratory ↑↑ in JVP) \+/-Pulsus paradoxus Severe leg edema, hepatomegaly, ascites Pericardial knock
What are some physical findings of CP?
Early diastolic sound due to abrupt cessation of ventricular filling when rigid pericardial limit reached (just before S3 in timing, corresponds to y descent)
What may be ssen on CXR for CP?
CXR pericardial calcification
What is the treatment for CP?
Diuretics improve congestive symptoms
Only definitive therapy is surgery with removal of the pericardium (Pericardiectomy)
—> Difficult to remove all the visceral pericardium (stuck to epicardium), can result in surgical failure
What are features in RA pressure tracings?
increase JVP with prominent X´ & Y descents
T or F: CXR/ECG rarely help for CP
T
What can confirm CP?
Heart catheterization confirms diagnosis
