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Year 3 > Pericardial disease (CV) > Flashcards

Pericardial disease (CV) Flashcards

1
Q

Define pericarditis.

A

Inflammation of the pericardium (outer sac) - may be acute or chronic

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2
Q

What is acute pericarditis?

A

New-onset pericardial inflammation lasting <4 to 6 weeks

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3
Q

What is acute pericarditis commonly caused by?

A

Viral infection

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4
Q

What is chronic pericarditis?

A

Lasts >3 months

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5
Q

What does chronic pericarditis lead to?

A

Constrictive pericarditis - impedes normal diastolic filling

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6
Q

When can constrictive pericarditis be caused? (2)

A
  • chronic pericarditis leads to constrictive pericarditis
  • medium to late complication of acute pericarditis
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7
Q

What are the clinical features of constrictive pericarditis? (4)

A
  • dyspnoea
  • right heart failure - peripheral oedema
  • Kussmaul’s sign - paradoxical rise in JVP on inspiration, caused by impaired filling of RV due to poorly compliant myocardium/pericardium (JVP should normally fall with inspiration due to reducing pressure in thoracic cavity)
  • pulsus paradoxus (sign of tamponade but also seen here) - SBP falls >10 on inspiration
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8
Q

What are the signs of constrictive pericarditis? (7)

A
  • Kussmaul’s sign (paradoxical rise in JVP on inspiration)
  • pulsus paradoxus
  • peripheral oedema
  • ascites
  • hepatomegaly
  • pericardial knock (rapid ventricular filling) - early diastolic sound
  • atrial fibrillation
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9
Q

What does Kussmaul’s sign help us differentiate between (pericarditis)?

A

Constrictive pericarditis (due to chronic pericarditis) and cardiac tamponade - sign not present in tamponade

Cardiac tamponade = fluid in pericardial sac

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10
Q

What might a CXR show in constrictive pericarditis?

A

Pericardial calcification

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11
Q

Which groups does pericarditis affect most? (2)

A
  • M>F
  • most common in 20-50 year olds
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12
Q

What is the aetiology of pericarditis?

A

Idiopathic

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13
Q

What is Dressler’s syndrome?

A

Pericarditis several weeks/months after an MI, that may occur with/without effusion

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14
Q

What are the features of Dressler’s syndrome (pericarditis)? (4)

A
  • acute pleuritic chest pain
  • fever
  • raised ESR
  • SOB worse when lying down and better when sitting forward
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15
Q

What would you see on ECG in Dressler’s syndrome (pericarditis)? (3)

A
  • widespread concave ST elevation
  • PR depression with reciprocal ST depression
  • PR elevation in aVR
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16
Q

How is Dressler’s syndrome (pericarditis) treated? (2)

A
  • NSAIDs preferably
  • prolonged course of colchicine or steroids
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17
Q

What are the clinical features of pericarditis? (4 + 8)

A
  • chest pain
    • pleuritic
    • sharp
    • acute
    • severe
    • central
    • radiates to neck/shoulders on LHS
    • worse when lying flat, coughing, deep inspiration
    • relieved by leaning forward/sitting up
  • fever
  • myalgia
  • dyspnoea
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18
Q

What might you see on examination of pericarditis? (4)

A
  • pericardial friction rub - superficial scratchy/squeak sound over lower left sternal border, patient leaning forward at end expiration (sounds like leather rubbing against each other)
  • fever
  • faint heart sounds (due to pericardial effusion)
  • cardiac tamponade signs (fluid build-up in pericardium and constricts heart)
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19
Q

What is cardiac tamponade (pericarditis complication)?

A

Fluid accumulates in pericardial space and constricts the heart, preventing effective contraction –> cardiogenic shock

20
Q

What are the features of cardiac tamponade (pericarditis complication)? (2)

A
  • Beck’s triad - raised JVP, decreased BP, muffled heart sounds
  • pulsus paradoxus - large drop in BP during inspiration
  • (to distinguish - pericarditis has Kussmaul’s sign)
21
Q

What triad is seen in cardiac tamponade (pericarditis)?

A

Beck’s triad:

  • raised JVP
  • decreased BP
  • muffled heart sounds
22
Q

What investigation is diagnostic for cardiac tamponade and what would you see?

A

ECG showing electrical alternans (different sized QRS complexes)

23
Q

What triad is seen in pericarditis?

A
  1. chest pain - sharp, reverse, retrosternal, worse on inspiration/supine
  2. pericardial friction rub
  3. serial electrocardiographic changes
24
Q

How can we differentiate pericarditis from myocarditis?

A

Myocarditis has acute pulmonary oedema

25
Q

What are some risk factors for pericarditis? (10)

A
  • M>F
  • 20-50y
  • transmural MI
  • cardiac surgery
  • infection (Coxsackie B, Hx of cold/flu Sx)
  • connective tissue disease (sarcoidosis, SLE, scleroderma)
  • malignancy
  • uraemia
  • systemic autoimmune disorders (RA, SLE)
  • other causes - radiotherapy, thoracic surgery, drugs, Behcet’s syndrome, trauma
26
Q

What are the first-line investigations for pericarditis? (4)

A
  • ECG
  • serum troponin
  • pericardiocentesis
  • CRP
27
Q

What scans do we do in pericarditis? (3)

A
  • ECG
  • transthoracic echocardiography - pericardial effusion, cardiac tamponade may be present
  • CXR - pericardial effusion (globular)
28
Q

What would ECG show in pericarditis? (3)

A
  • widespread saddle-shaped ST elevation in all leads with no reciprocal changes
  • PR depression (later followed by T-wave flattening and inversion)
  • tachycardia
29
Q

What does serum troponin show in pericarditis?

A

Elevated indicates myopericarditis or other aetiologies such as ACS

30
Q

What does elevated urea indicate in pericarditis?

A

Uraemic cause

31
Q

When do you do pericardiocentesis in pericarditis?

A

If you suspect cardiac tamponade, do urgent pericardiocentesis and send pericardial fluid for analysis

  • acid-fast bacilli, positive culture of Mycobacterium tuberculosis
  • transudate or exudate
32
Q

Why would you do a blood culture in pericarditis?

A

Positive if infective cause

33
Q

What are some differential diagnoses for pericarditis? (5)

A
  • pulmonary embolism
  • MI or ischaemia
  • pneumonia
  • pneumothorax
  • costochondritis
34
Q

What is the diagnostic criteria for acute pericarditis (new onset, <4-6 weeks)?

A

Inflammatory pericardial syndrome associated with 2+ of the following 4 criteria:

  • characteristic chest pain - typically sharp, pleuritic, and relieved by sitting forwards
  • pericardial friction rub
  • new widespread diffuse concave upwards ST elevation and/or PR depression on ECG
  • new or worsening pericardial effusion
35
Q

What is the diagnostic criteria for chronic pericarditis?

A

Signs and symptoms persisting for >3 months

36
Q

What are some subtypes of pericarditis? (3)

A
  • constrictive: due to chronically thickened pericardium
  • effusive-constrictive: combination of tense effusion in pericardial space and constricted by the thickened pericardium
  • adhesive: non-constrictive
37
Q

How do we often manage pericarditis?

A
  • often self-limiting - triage and consider hospital admission
  • NSAIDs can help alleviate symptoms - aspirin, ibuprofen, naproxen
  • PPI prophylaxis to protect against effects of high doses of NSAIDs
  • treat potential underlying cause - TB, immune processes, metabolic disorders, cardiac surgery
38
Q

When do we consider hospital admission in pericarditis? (5)

A

Underlying aetiology OR high-risk features:

  • high fever >38
  • subacute course (Sx over several days without clear-cut acute onset)
  • evidence of large pericardial effusion (diastolic echo-free space >20mm)
  • cardiac tamponade
  • failure to respond within 7d to NSAIDs
39
Q

When do we do pericardiocentesis in pericarditis?

A

If you suspect cardiac tamponade

40
Q

How do we manage idiopathic or viral pericarditis (non-purulent)?

A
  • NSAID plus PPI
  • colchicine - adjuvant therapy which improves response to medical Rx and reduces rate of recurrence
    • main side effect: diarrhoea
    • do NOT give colchicine if TB
41
Q

How do we manage purulent pericarditis?

A
  • IV Abx (anti-Staphylococcus + aminoglycoside)
  • specialist management
42
Q

What is the surgical management for cardiac tamponade?

A
  • pericardiocentesis - pericardial needle aspiration
  • neoplastic disease: percutaneous balloon pericardiotomy
43
Q

What is the surgical management for pericarditis in recurrent disease?

A

Pericardiectomy (complete removal of pericardium) - in cases of constrictive pericarditis, or TB that does not resolve

44
Q

What are some complications of pericarditis? (3)

A
  • pericardial effusion (urgent pericardiocentesis)
  • cardiac tamponade (urgent pericardiocentesis)
  • chronic constrictive pericarditis
45
Q

What are poor prognostic signs of pericarditis? (5)

A
  • high fever >38
  • subacute course (over several days, no clear-cut acute onset)
  • evidence of large pericardial effusion (diastolic echo-free space >20mm)
  • cardiac tamponade
  • failure to respond within 7 days to NSAIDs

Year 3 (175 decks)

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