Pericardial Disease

Question 1

Acute Pericarditis

Answer 1

<6 weeks Fibrinous Effusive (serous or sanguinous)

Question 2

Subacute Pericarditis

Answer 2

6 weeks to 6months effusive-constrictive constrictive

Question 3

Chronic Pericarditis

Answer 3

>6 months contrictive effusive adhesive (non-constrictive)

Question 4

Major causes of pericardial disease

Answer 4

● Idiopathic ● Infectious ● Radiation ● Neoplastic ● Cardiac ● Trauma ● Autoimmune ● Drug ● Metabolic

Question 5

Pericardial Effusion

Answer 5

Diagnostic studies ● CxR ● Normal if effusion is small ● If >250ml, then the heart changes shape

Question 6

Radiation

Answer 6

related to amount of exposure can lead to restrictive pericarditis

Question 7

Neoplastic

Answer 7

Metastatic ● Lung, breast, Hodgkin’s, leukemia Primary ● Rhabdomyosarcoma, teratoma, fibroma, lipoma Paraneoplastic

Question 8

Hemorrhagic pericarditis

Answer 8

● Blood in the pericardium ● Commonly after cardiac surgery ● Malignancy ● Tuberculosis ● Systemic anticoagulation

Question 9

Young, otherwise healthy

Answer 9

Lupus

Question 10

With fever, cytopenia

Answer 10

viral

Question 11

Elderly, hx cancer

Answer 11

cancer

Question 12

MI 1 month prior

Answer 12

dressler’s

Question 13

CKD, not on dialysis

Answer 13

Uremic

Question 14

What pericaditis hurts? doesnt?

Answer 14

infectious/inflammatory uremic and malignant

Question 15

Pericardial fluid testing

Answer 15

● Culture(s), gram-stain ● Viral PCR/viral culture ● Cell count ● Protein ● LDH ● Glucose

Question 16

Anatomy of Pericardium

Answer 16

● Pericardium is contiguous with the retropharyngeal space (between the alar fascia and prevertebral fasica ● Abcess can track

Question 17

Diagnostic Approach

Answer 17

● Echocardiogram − May find a pericardial effusion ● PPD ● Connective tissue screen − ANA, rheumatoid factor − SED rate, ● Mild elevations in cardiac enzymes are typical ● Search for cancer!! − Lung and breast. ● Do a CxR and breast exam.

Question 18

Physical Exam

Answer 18

● Pericardial friction rub present in 85% of acute pericarditis ● End-expiration, leaning forward, upright position ● Heart sounds may be distant

Question 19

Treatment of Pericarditis

Answer 19

● Treat underlying cause – SLE, cancer, sarcoidosis, uremia ● NSAIDS – ketorolac, naproxyn, ibuprofen, indomethacin ● Aspirin ● Colchicine ● Limited by renal / GI safety – steroids also effective

Question 20

Cardiac Tamponade

Answer 20

● Hypotension ● Tachycardia ● JVD ● RV compression on echo ● IVC distension on echo, without respiratory phasic collapse ● May occur with only minimal effusion ● Don’t wait for the echo – get help immediately

Question 21

Infectious Pericarditis

Answer 21

Viral Pyogenic Tuberculin Fungal Other infection

Question 22

Noninfective Pericarditis

Answer 22

Acute MI Uremia Neoplasia -primary tumors (benign, malignant, mesothelioma) -tumors metastatic to pericardium (lung, breast, lymphoma, leukemia) Myxedema Cholesterol Chylopericardium Trauma (penetrating, non) Aortic Disection (w leakage) Postirradiation Familial Mediterranean Fever Familial Pericarditis (Mulibrey nanism) Acute idiopathic Whipple’s Disease Sarcoidosis

Question 23

Pericarditis presumably related to hypersensitivity or autoimmunity

Answer 23

Rheumatic fever collagen vascular disease (SLE, RA, ank spond, scleroderma, acute rheumatic fever, Wegner’s) Drug-induced Postcardiac injury 1. postMI (dressler’s) 2. Postpericardiotomy 3. Posttraumatic