Pericardial diseases

Question 1

Difference between the EKGs of pericarditis and stemi

Answer 1

STEMI: convex ST-elevation (not diffuse), normal PR segment. Look like tomb stones

Pericarditis: concave ST-elevation (diffuse in all leads), PR segment depression

Question 2

Where is the pericardium and the function?

Answer 2

Outmost layer

Double-layered sac (fibrous and serious)
Exerts a restraining force,
Prevents sudden dilation of the cardiac chambers during exercise and with hypervolemia
Restricts the anatomic position of the heart
Decreases the spread of infections from the lungs and pleural cavities to the heart.

Question 3

What is pericarditis and what is the MC cause?

Answer 3

Inflammation of pericardial sac

Idiopathic is MC (typically viral), but can be
Infectious
Systemic diseases
Neoplasms
Drug toxicity
Pericardial Injury
Myocardial injury

Question 4

What is the MC cause of infectious pericarditis?

Answer 4

Viral (MC cause)
Bacterial and TB can be as well

Question 5

What systemic diseases can cause endocarditis?

Answer 5

Hypothyroidism
Inflammatory diseases
CKD d/t uremic pericarditis

Question 6

What are the MC neoplasms that can cause endocarditis?

Answer 6

Lung and breast are MC (make up half)

Question 7

What are the drug-induced causes of pericarditis and the MC?

Answer 7

MC is chemo (doxorubicin)
also
Penicillin and cromolyn sodium - induce a hypersensitivity reaction
Procainamide, hydralizine, methyldopa, isoniazid
Phenytoin and minoxidil

Question 8

What is dressler syndrome, and what does it lead to?

Answer 8

Dressler Syndrome – occurs later (2 weeks) due to a delayed autoimmune / inflammatory response

Question 9

What are the four principle diagnostic principles of pericarditis?

Answer 9

Chest pain
Pericardial friction rub
EKG changes
Pericardial effusion

Question 10

What is the cardinal symptom of pericarditis, and what exacerbates and makes it feel better?

Answer 10

Chest pain, retrosternal radiating to back, worse with activity (pleuritic chest pain) and laying down

Feels better by leaning forward d/t less pressure on heart

Question 11

What are the other common symptoms of pericarditis?

Answer 11

dyspnea and fever

Question 12

What is diagnostic evalutation of pericarditis?

Answer 12

clincal diagnoses
viral titers
cardiac enzymes
echocardiogram (serial)
CBC
BMP, thyroid
ESR, CRP

Question 13

What do you see in in all leads of EKG for pericarditis

Answer 13

1. ST elevation with PR depression (stage 1)
2. normalization
3. T wave inversion for months
4. Back to normal

Question 14

What does a CXR show for pericarditis?

Answer 14

Only ordered if suspected problems

Chest xray – typically normal, unless an underlying malignancy or lung process is identified, or a large effusion is present

CT or MRI may be necessary if malignancy is suspected

Question 15

What are the essentials of diagnosis of pericarditis?

Answer 15

Anterior pleuretic chest pain worse supine then upright
Pericardial rub
Fever (common)
ESR or inflammatory CRP elevated
ECG with diffuse ST-segment elevation with associated PR depression

Question 16

What is the first management of pericarditis?

Answer 16

NSAIDs
ASA taper if MI

Question 17

What are the reasons to consider inpatient management of pericarditis?

Answer 17

Fever > 100.4 (38.3)
Subacute onset
Immunosuppression
Trauma
Oral anticoagulation therapy
ASA or NSAID treatment failure
Myopericarditis
Large pericardial effusion or tamponade

Question 18

If someone is diagnosed with pericarditis, how to prevent recurrence?

Answer 18

Colchicine (anti-gout) is an adjuvant therapy
Corticosteroids if severe, refractory cases or if patients can’t tolerate NSAIDs or colchicine

Question 19

What is cardiac tamponade?

Answer 19

Pericardial effusion is too big and blood cannot flow into the heart

state of increased pressure, defined by progression - not volume

medical emergency
Right ventricle bows into left ventricle because of built up pressure

Question 20

What is the clinical presentation of pericardial tamponade?

Answer 20

Presentation will vary based on size of the effusion
If small – likely no symptoms or only symptoms of pericarditis
If large – may no longer have CP of pericarditis, but now with fatigue and shortness of breath
If hemodynamically significant (tamponade) – will have signs of cardiogenic shock

Question 21

What is the Beck’s triad of tamponade?

Answer 21

Distended jugular veins (increased JVD)
Distant/muffled heart sounds
Hypotension

not diagnotic or specific, but clues you in

Question 22

What are kussmaul’s sign and pulsus paradoxus?

Answer 22

Kussmaul’s Sign – increase in JVP on inspiration (instead of the normal decrease).

Pulsus Paradoxus – an inspiratory systolic fall in arterial pressure >12 mmHg during normal breathing (check BP with inspiration) – 70-80% of patients

Question 23

What are the diagnostic evaluation of EKG in cardiac tamponade?

Answer 23

Swinging in fluid, alterating the EKG voltage

variation of peak-to-peak QRS (low then high voltage)

ELECTRICAL ALTERNANS is pathognomonic of CARDIAC TAMPONADE.

Question 24

What does a CXR of pericardial effusion look like?

Answer 24

Water bottle heart in severe cases

Question 25

What is the initial test of choice for pericardial effusion?

Answer 25

TTE

When checking for tamponade, we look for 3 things:
RV Collapse
LV Collapse
Dilated IVC w/out inspiratory collapse

can also order a CT scan or MRI

Question 26

What is the management of small pericarditis?

Answer 26

Monitoring with serial echos

Question 27

When do you need to be admitted for pericarditis?

Answer 27

Fever (>38ºC [100.4ºF]) and leukocytosis
Immunosuppressed state
A history of therapy with V-K antagonists
Acute trauma
Failure to respond within seven days to NSAID therapy
Elevated cardiac troponin, which suggests myopericarditis

Question 28

How is pericarditis managed for mod/severe pericarditis?

Answer 28

Pericardiocentesis
Removing fluid from the pericardium

Diagnostic and therapeutic
For effusions >250 mL, effusions when size increases despite intensive dialysis for 10-14 days, or effusions with evidence of tamponade
Complications include fatal cardiac laceration.

Question 29

After doing a pericardiocentensis, what do you do with the fluid taken from the heart?

Answer 29

Send fluid off protein, RBC, bacteria

Question 30

If you have reccurent pericardial effusions, what do you do?

Answer 30

Pericardial Diodesis
Installation of chemical or other agents into the pericardial space

Act to cause sclerosis of the pericardium
Used for recurrent pericardial effusions

Pericardiotomy

Incision into the pericardium
Consider (subxiphoid or percutaneous balloon) pericardiotomy for large effusions that do not resolve.
May be performed under local anesthesia and has a lower risk of complications than pericardiectomy.
Effective (90-97%)

Pericardial Window
A surgical procedure to create a fistula - “window” - from the pericardial space to the pleural cavity, allowing the effusion to drain out of the pericardial space into the chest cavity.

Can be performed with a balloon catheter

Pericardiectomy
Removal of the pericardium (very rare but effective)

Question 31

Otomy vs ectomy?

Answer 31

otomy = opening
ectomy = taking out

Question 32

A 56-year-old woman with a 6-year history of stage II cancer of the left breast presented with progressive shortness of breath and fatigue.
Physical examination revealed hypotension, tachycardia, jugular venous distention, pulsus paradoxus, and distant heart sounds; the blood pressure was 63/44 mm Hg, and the heart rate 110 beats per minute.
The following is a view of her chest x-ray (water bottle) and EKG (elevated followed by depressed QRS)

Transthoracic echocardiography revealed a large pericardial effusion with swinging of the heart freely in an anterior–posterior fashion (see video) and collapse of the right and left atria in end diastole.

Pericardiocentesis resulted in drainage of 1.3 liters of bloody fluid, which was subsequently attributed to a malignant effusion.
Repeat echocardiography over the next 6 hours revealed reaccumulation of effusion.
The patient subsequently had cardiac arrest and died.

Answer 32

This is cardiac tamponade

:(

Question 33

What is constrictive pericarditis?

Answer 33

Scarring of pericarditis causing thickening of fibrotic tissue

Inflammation of the pericardium can lead to a thickened, fibrotic, adherent pericardium
This restricts diastolic filling, which predominantly presents as right heart failure
TB most common cause in developing countries
Radiation, cardiac surgeries and viral pericarditis most common causes in developed countries

Question 34

What is the clinical presentation of constrictive pericarditis?

Answer 34

Progressive dyspnea, fatigue and weakness
Signs of Right Heart Failure – edema, ascites, hepatic congestion
Elevated JVP – Kussmaul sign
Atrial fibrillation is common

Question 35

What is the confirmatory test for constrictive pericarditis?

Answer 35

Cardiac catheterization
Allows for the simultaneous measurement of intracardiac pressures in the RV and LV, during inspiration and expiration

Question 36

What is the management of constrictive pericarditis? What if it is not effective?

Answer 36

Loop diuretics or aldosterone antagonist

Surgical pericardiectomy if unresponsive

Question 37

Overview of pericarditis

Answer 37

inflammation
pericardic friction rub
ST elevation in all leads PR depression
Pain

Question 38

A 32-year-old woman comes to the emergency department because of a 3-week history of progressive exertional dyspnea. She reports that she has to stop and rest after walking a single block. She has no dyspnea at rest and has otherwise felt well. She has a 5-year history of systemic lupus erythematosus.

Her pulse is 105/min, respirations are 22/min, and blood pressure is 110/72 mm Hg.

Cardiac examination shows distant heart sounds and jugular venous distention. Bibasilar crackles are heard.

EKG is ordered

What does she have?
What should is the next step of management?

Answer 38

Cardiac tamponade
order a transthoracic echocardiography

Question 39

A 30-year-old woman comes to the emergency department because of sharp chest pain for one day. She first felt the pain as she was sitting on her couch watching television. The pain is in the center of her chest and is worse with deep inspiration and coughing. She reports that her pain improves when she leans forward while sitting.

What is at the top of our differential?
What do we want to order?
What abnormalities would you see on EKG?
Treatment?

Answer 39

Pericarditis (inflammation)
Labs, EKG, chest xray, CBC, BMP
Diffusion
High dose NSAIDs