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ICM Exam 3 Cardiology > Pericardial Disease - Tubin > Flashcards

Pericardial Disease - Tubin Flashcards

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1
Q

Pericardium - amt of plasma ultrailtrate

A

15-50 mL

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2
Q

Pericarditis can be ___ or ____

A

acute or recurrent

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3
Q

Acute Pericarditis - most common cause

A

idiopathic

(always say “viral”)

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4
Q

Causes of acute pericarditis (5)

A
  1. Radiation
  2. Neoplasm (primary, met, or paraneo)
  3. Trauma
  4. AI
  5. Metabolic (Hyperthyroid, Uremia)
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5
Q

In trauma-induced pericarditis, inflammation in the chest will be accompanied by

A

effusion

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6
Q

Infecirious causes of pericarditis

A

Viral = Cox AB, Echo, mumps, adeno, HIV

Bacterial = TB, Pneumococcus, strep, staph, legionella

Fungal = histo, coccidio, candida, blasto

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7
Q

Infectious pericarditis rarely caused by

A

syphillis

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8
Q

____ pericarditis d/t TB

A

Purulent

(PICTURE)

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9
Q

Pericardial effusion can cause partial _________

A

collapse of atria

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10
Q

Cardiac causes of Pericard.

A

Early infarction

late post cardiac injury (dresslers)

Myocarditis

Dissecting aortic aneurysm

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11
Q

Dressler’s syndrome =

A

late post cardiac injury

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12
Q

Difficult to tell _______ with echo

A

nature of effusion

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13
Q

Unstable pericardial effusion - what not to do

A

immediately drain- have to rule out aortic dissection because if present, you’ve just opened up a space for blood to enter

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14
Q

Blood clots forming in P. effus. may appea ____ on echo

A

strand-like

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15
Q

Drug induced pericarditis caused by…

A

Procainamide

Isoniazid

Hydralazine

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16
Q

Usually fluid is ______

Look for what?

Sometimes you’ll see ____ in bact. infection

A

serous

bacterial or tumor cells

Purulent pericarditis – need aggressive Tx

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17
Q

Fluid in PEff may…

A

resolve or form adhesions

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18
Q

Clinical features of pericarditis

A
  • CHEST PAIN (main)
  • Friction rub
  • ECG changes
  • Pericrdial effusion
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19
Q

Friction rub is

A

3 component rub

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20
Q

Best diagnostic tool for acute pericarditis

A

ECG

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21
Q

Chief complaint for pericarditis

A

Chest pain unrelated to exertion

(nonspecific complaints = Fatigue, dyspnea, malaise, fever)

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22
Q

Differentiate from MI in complaint

A

MI doesn’t tend to have many preceding symptoms

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23
Q

Chest pain is present in ____

A

95% of cases

more comon with infection, less common with uremic or rheum.

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24
Q

Chest pain locaiton

A

anterior chest wall

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25
Chest pain description Better/worse when...
Sudden onset Sharp, pleuritic in nature * Worse when laying flat, inspiration, or coughing, * Better when seated or leaning forward.
26
Rub is d/t
friction between visceral and parietal layers of pericardium
27
3 parts of rub
First == systole Second = ventricular diastole Third = atrial systole
28
Rub description
triphasic (50-60%) Biphasic (30%) scratchy/leathery sound
29
Eval for acute (8)
1. History, exam, ECG 2. ESR, CBC, chem 3. Troponin 4. CXR 5. Echo (if suspected effusion) 6. NO viral studies 7. AI serologies 8. Pericardiocentesis
30
CXR in acute pericarditis is...
usually normal
31
When do you do an echo with acute pericarditis
if suspected concurrent effusion
32
\_\_\_\_ helps you decide urgency /necessity of hospitalization
troponin | (rule out MI)
33
May see _____ in echo which is relatively \_\_\_\_\_\_
increase in brightness nonspecific
34
ECG findings with acute pericarditis
ST segment (esp in aVr) PR segment
35
Type of ST change we are looking for in AP
**diffuse** ST concavity (vs ischemic change which would be very location specific depending on the occluded vessel)
36
PR change we look for in AP
PR depression
37
Changes in aVr are \_\_\_\_\_\_
Inverse \*\*impotant, will show ST depressions and PR elevations\*\*
38
Stadium 2 =
Smaller PR
39
Stadium 3
T wave inversion
40
In Early repolarization slide, J point and ST elevtion is most prominent in
V4-6
41
Ddx
* Acute coronary syndrome * myocarditis * pleurisy * PNA * PE * Aoritc dissection * Pneumothorax * Musculoskeletal * Esophageal
42
Medical therapy
Combo of NSAID and Colchicine Colchicine = **3 months** NSAIDS = indometh, ibuprofen for **1 month** (and titrate down before stopping)
43
Would not use ibuprofen after...
MI use high dose aspirin instead
44
Colchiine AE
diarrhea P450 metabolism (DDI)
45
Colchicine not good with
severe renal or liver disease blood dyscrasias or GIT motility problems
46
Cautions use of NSAIDS with
renal insufficiency
47
Glucocorticoids for
**refractory** symptoms Acute pericarditis due to **connective tissue or uremic**
48
P effusion creates
tamponade if starts pushing on heart
49
Types of effusion
fast and small slow and large
50
3 Complications of AP
effusion and tamponade constrictive pericarditis (late) Relapse
51
9 Causes of Pericard eff
1. Acute pericarditis 2. Radiation 3. Malignancy 4. Cardiac perforation 5. Hypothyroidism 6. Connective Tissue disease 7. Post-MI 8. Chronic Renal failure 9. Aortic dissection
52
CXR appeaerance of Peri effusion
Highly enlarged shadow
53
Main tool for pericardial effusion
Echo
54
Presentation of Tamponade
(depends on chronicity) * **CHF Sx** -- Dyspnea, fatigue (but clear lungs) * Unexplained **RHF symptoms** (Edema, JVP) * New **cadiomegaly** on CXR * **Sinus Tach**, Low voltage electrical **alternans**
55
ECG finding in P effusion/tamponade
Electrical alternans
56
Tamponade pathophys (6)
1. Increased Intrapericardial pressure (impees diastolic filling of LV) 2. Diastolic pressure rises in RV and LV 3. SO and CO decrease 4. BP drops 5. Narrow PP 6. HR increases
57
Pulsus paradoxus
Fall of systolic BP **\>10 mmHg** with inspiration (Exaggerated *drop in systemic BP* during inspiration)
58
Inspiration causes diaphragm to fall and
RV to fill passively and expand (to an extent)
59
If heart is constrained, the venous return causes
Septal shift to compress/impinge on the LV volume --\>Pulsus paradoxus
60
How to check for pulsus paradoxus
1. Get BP regularly 2. Slowly pump up cuff 20mm above first korotkoff sound 3. Slowly deflate and let breathe naturally 4. Hear occasional waves that get through 5. Start hearing more frequent sounds as cuff sounds (until hearing every heart sound) 6. Pulsus paradoxus difference will be more than 10
61
Tamponade findings (5)
* Tachycardia + Tachypnea * Hypotension with narrow PP * Elevated JPV with *loss of Y descent* * Peripheral Edema * Pulsus Paradoxus
62
JVP components
A = atrial contract V = Passive filling X trough = Drop in atrial pressure after active contraction Y trough = ventricle filling after mitral opening
63
Eval for Tamponade
History/Exam ECG + CXr Echo with doppler RIght heart cath (to equalize pressure)
64
Treatment for Tamponade
\*Medical emergency\* * IVF (temporizing) * Vasopressors as needed * Pericardiocentesis * Pericardial window
65
Avoid what in tamponade treatment
diuretics, vasodilators, etc. last thing you want to do is decrease the vascular volume
66
Three ECG findings for Tamponade
Sinus tach low voltage Electrical alternans
67
Pericardial fluid analysis (5)
* Gram stain and bacterial/fungal culture * Cytology * AFB stain and mycobact culture with ADA, IFNg, or lysozyme * PCR * Protein, LDH, RBC/WBC
68
Labs for Tamponade
Cardiac enzymes Inflammatory (CRP, ESR) Thyroid Renal fxn Body fluid cultures PPD
69
Constrictive pericarditis pathophys
Chronic thickening/scarring encasement of heart and impaired diastolic fililng EARLY DIASTOLIC FILLING IS OKAY Chambers collide with constricted pericardium upon filling
70
Signs for constric. pericarditis
Dip and Plateau sign OR Square root sign
71
Causes of constritive peric.
idiopathic/viral Surgery Radiation CT disease TB, bact misc
72
Clinccal presentation of CP
Slow indolent process Unexplained RHF
73
Const. pericard is often misdiagnosed as..
cirrhosis
74
Constrictive pericard physical findings
Elevated JVP (prominent X and Y) Kussmaul's sign Pericardial knock Systemic congestion
75
Kussmauls sign =
Lack of an inspiratory decline in JVP (JVP normally dips on inspiration, in kussmauls it is increased-- because the blood that is pulled in has nowhere to go due to restriction, and it backs up)
76
Tamponade vs Constriction JVP
No Y descent on tamponade Constriction has prominent X and Y
77
Constrictive Pericarditis evaluation (6)
* H+P * CXR * Chest CT (pericardial thickening) * MRI * Echo * Simultaneous R and L heart hemodynamics (equalization of pressures)
78
Constrictive pericarditis on XRAY
**pericardial thikening and calcification** that even hellen keller could see
79
Therapy for constrictive pericarditis
_Acute_ = diuresis (but don't overdiurese, only until Sx relieved) _Long term_ = Pericardial stripping (surgery)

ICM Exam 3 Cardiology (8 decks)

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