Pericardial diseases Flashcards
Difference between the EKGs of pericarditis and stemi
STEMI: convex ST-elevation (not diffuse), normal PR segment. Look like tomb stones
Pericarditis: concave ST-elevation (diffuse in all leads), PR segment depression
Where is the pericardium and the function?
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.
What is pericarditis and what is the MC cause?
Inflammation of pericardial sac
Idiopathic is MC (typically viral), but can be
Infectious
Systemic diseases
Neoplasms
Drug toxicity
Pericardial Injury
Myocardial injury
What is the MC cause of infectious pericarditis?
Viral (MC cause)
Bacterial and TB can be as well
What systemic diseases can cause endocarditis?
Hypothyroidism
Inflammatory diseases
CKD d/t uremic pericarditis
What are the MC neoplasms that can cause endocarditis?
Lung and breast are MC (make up half)
What are the drug-induced causes of pericarditis and the MC?
MC is chemo (doxorubicin)
also
Penicillin and cromolyn sodium - induce a hypersensitivity reaction
Procainamide, hydralizine, methyldopa, isoniazid
Phenytoin and minoxidil
What is dressler syndrome, and what does it lead to?
Dressler Syndrome – occurs later (2 weeks) due to a delayed autoimmune / inflammatory response
What are the four principle diagnostic principles of pericarditis?
Chest pain
Pericardial friction rub
EKG changes
Pericardial effusion
What is the cardinal symptom of pericarditis, and what exacerbates and makes it feel better?
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
What are the other common symptoms of pericarditis?
dyspnea and fever
What is diagnostic evalutation of pericarditis?
clincal diagnoses
viral titers
cardiac enzymes
echocardiogram (serial)
CBC
BMP, thyroid
ESR, CRP
What do you see in in all leads of EKG for pericarditis
- ST elevation with PR depression (stage 1)
- normalization
- T wave inversion for months
- Back to normal
What does a CXR show for pericarditis?
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
What are the essentials of diagnosis of pericarditis?
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
What is the first management of pericarditis?
NSAIDs
ASA taper if MI
What are the reasons to consider inpatient management of pericarditis?
Fever > 100.4 (38.3)
Subacute onset
Immunosuppression
Trauma
Oral anticoagulation therapy
ASA or NSAID treatment failure
Myopericarditis
Large pericardial effusion or tamponade
If someone is diagnosed with pericarditis, how to prevent recurrence?
Colchicine (anti-gout) is an adjuvant therapy
Corticosteroids if severe, refractory cases or if patients can’t tolerate NSAIDs or colchicine
What is cardiac tamponade?
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
What is the clinical presentation of pericardial tamponade?
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
What is the Beck’s triad of tamponade?
Distended jugular veins (increased JVD)
Distant/muffled heart sounds
Hypotension
not diagnotic or specific, but clues you in
What are kussmaul’s sign and pulsus paradoxus?
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
What are the diagnostic evaluation of EKG in cardiac tamponade?
Swinging in fluid, alterating the EKG voltage
variation of peak-to-peak QRS (low then high voltage)
ELECTRICAL ALTERNANS is pathognomonic of CARDIAC TAMPONADE.
What does a CXR of pericardial effusion look like?
Water bottle heart in severe cases
What is the initial test of choice for pericardial effusion?
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
What is the management of small pericarditis?
Monitoring with serial echos
When do you need to be admitted for pericarditis?
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
How is pericarditis managed for mod/severe pericarditis?
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.
After doing a pericardiocentensis, what do you do with the fluid taken from the heart?
Send fluid off protein, RBC, bacteria
If you have reccurent pericardial effusions, what do you do?
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)
Otomy vs ectomy?
otomy = opening
ectomy = taking out
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.
This is cardiac tamponade
:(
What is constrictive pericarditis?
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
What is the clinical presentation of constrictive pericarditis?
Progressive dyspnea, fatigue and weakness
Signs of Right Heart Failure – edema, ascites, hepatic congestion
Elevated JVP – Kussmaul sign
Atrial fibrillation is common
What is the confirmatory test for constrictive pericarditis?
Cardiac catheterization
Allows for the simultaneous measurement of intracardiac pressures in the RV and LV, during inspiration and expiration
What is the management of constrictive pericarditis? What if it is not effective?
Loop diuretics or aldosterone antagonist
Surgical pericardiectomy if unresponsive
Overview of pericarditis
inflammation
pericardic friction rub
ST elevation in all leads PR depression
Pain
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?
Cardiac tamponade
order a transthoracic echocardiography
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?
Pericarditis (inflammation)
Labs, EKG, chest xray, CBC, BMP
Diffusion
High dose NSAIDs
