Pericardial Diseases Flashcards
normal functions of pericardium
- Double-layered sac
- 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.
causes of pericarditis, MC? (7)
- Defined as inflammation of the pericardial sac
- Wide array of possible causes:
- Idiopathic (MC)
- Infectious - viral MC
- Systemic diseases
- Neoplasms
- Drug toxicity
- Myocardial injury
- Pericardial Injury
infectious causes of pericardial dz, MC?
-
Viral
- Coxsackievirus, echovirus, influenza, varicella, hepatitis, HIV, measles, mumps, CMV, RSV
- Have seasonal peaks. MC in males - Bacterial
- Rare; if occurs, likely an extension of pulmonary infections - TB
- Rare in developed countries
systemic disease causes of pericarditis
- Hypothyroidism
- Inflammatory Diseases
- SLE, RA, Scleroderma, Sarcoidosis, IBD, Polymyositis, and so on - CKD – results in uremic pericarditis
5-10% of pericarditis cases are due to ____, which enter the pericardium via blood, lymph, or direct penetration
cancers (neoplasms)
MC neoplasms that make up over half of cancer pericarditis cases
- Lung & Breast
- Renal cell CA, Leukemias, Lymphomas, and malignant melanomas make up most of the other portion
drug-induced causes of pericarditis
- PCN and cromolyn sodium - induce a hypersensitivity reaction
- Anthracycline chemo agents (doxorubicin and cyclophosphamide) have direct cardiac toxicity (MC)
- Procainamide, hydralazine, methyldopa, isoniazid - develop a drug-induced lupus syndrome, leading to pericarditis
- Phenytoin and minoxidil – unknown mechanism
types of pericardial injury to cause pericarditis
- Invasive cardiac procedures
- Pacemakers, ICDs, PCI, Ablations - Post-pericardiotomy
- Post cardiac surgeries, such as CABG, valve replacements, and so on
- Thought to be an exaggerated immune response to the injury - Trauma
- Blunt or penetrating - Radiation
- Occurs with high doses in the areas overlying or surrounding the heart
myocardial injury types to cause pericarditis
- Post-MI
- Follows a transmural MI; usually indicates a LARGE MI
- Occurs 2-5 days following the MI
- Dressler Syndrome – occurs later (2 weeks) due to a delayed autoimmune / inflammatory response - Post-cardiotomy
- Post cardiac surgeries, such as myomectomy for HCM - Trauma
- Blunt or penetrating
pt is having chest pain, precordial or retrosternal with referral to the trapezius ridge, neck, left shoulder, and arm.
Has a fever
worsened by deep breathing
worse when lying flat, during swallowing or coughing, with body motion
relieved by sitting up and leaning forward; not affected by eating or exertion
what is the dx?
pericarditis
Dyspnea may be present, especially if there is an effusion
Fever is common
4 principle diagnostic features for pericarditis
- Chest Pain
- Pericardial Friction Rub
- EKG
- Pericardial Effusion
what is the cardinal sx of pericarditis? cause?
Chest Pain
caused by the heart rubbing against the pericardium
what sound do you hear on auscultation with pericarditis
Pericardial Friction Rub
Characteristic heart sounds of pericarditis
Present with or without fluid accumulation
diagnostic evaluation/findings with pericarditis
typically clinically w/ little labs performed or needed
1. Viral titers / panel may be obtained if warranted
2. Cardiac enzymes
- May be elevated if myocardium is involved
3. Echocardiogram – obtain on all suspected pericarditis patients
- Most likely normal, unless significant effusion has developed
4. CBC – elevated WBC
5. BMP, Thyroid function tests
6. ESR, CRP
diffuse ST segment elevation, progresses to T wave inversions
PR segments are depressed
what is this EKG showing?
pericarditis
why do we see the ekg changes in acute pericarditis
- generalized inflammation of pericardium thus affecting both the ventricles (ST-T changes) and atria (PR changes).
- PR segment depressed due to atrial injury
As a result, Pericarditis ECG changes are seen in most, if not all, leads including:
how is it different from a STEMI?
- ST elevation–
- diffuse, in both anterior and inferior precordial leads, with reciprocal ST depression in aVR
- upward concavity morphology
- less prominent than in STEMI - PR depression–
- diffuse, in both anterior and inferior precordial leads, with reciprocal PR elevation in aVR
- is discordance with ST segment (i.e. PR depression & ST elevation in the same lead) - T inversion–
- only seen on occasions
- less prominent than in STEMI
management goals for pericarditis
Determine inpatient or outpatient treatment
Treat symptoms / resolve the inflammation
Prevent recurrence
Address underlying cause if possible
CXR and CT/MRI findings of pericarditis
- CXR – normal, unless an underlying malignancy or lung process is identified, or a large effusion is present
- CT / MRI may be necessary if malignancy is suspected
tx for pericarditis
-
NSAIDs are first-line
- Ibuprofen or Indomethacin
- Continue for 1 to 2 weeks, then taper over next 2 weeks - ASA - post-MI cases (1-2 wks, then taper over 2 wks)
- Address Underlying Causes
- TB - Standard anti-TB drug regimen - Uremia due to ESRD
- Dialysis is key
- Chronic pericarditis with production of effusions is common
- NSAIDs - supportive - Prognosis is poor if due to malignancy
If the following are present, consider inpatient management for Acute Pericarditis
Fever > 100.4 (38.3)
Subacute onset
Immunosuppression
Trauma
Oral anticoagulation therapy
ASA or NSAID treatment failure
Myopericarditis
Large pericardial effusion or tamponade
recurrence prevention of pericarditis
- Colchicine is an adjuvant therapy
- Corticosteroids
- Not used routinely; only if underlying disease process needs them (auto-immune or inflammatory diseases)
- May also be used in severe, refractory cases or if patients can’t tolerate NSAIDs or colchicine
- Prednisone 0.25-0.5 mg/kg/day
cause of pericardial effusion/tamponade
- Same causes of pericarditis can lead to an effusion
- Also, because pericardium covers the ascending aorta and arch, aortic dissection / rupture can lead to a pericardial effusion or tamponade
____ is a state of increased pressure
No specific amount of fluid is required. Depends more on the rate of accumulation
what is it characterized by?
tamponde
elevated intrapericardial pressure, leading to decreased venous return and ventricular filling = Reduced CO
presentation difference between small vs large cardiac tamponade
- small – likely no symptoms or only symptoms of pericarditis
- large – may no longer have CP of pericarditis, but now with fatigue and shortness of breath
- hemodynamically significant (tamponade) – will have signs of cardiogenic shock
what is Beck’s Triad
- distant/muffled heart sounds
- distended JVD
- hypotension
this clinical presentation sign shows an increase in JVP on inspiration (instead of the normal decrease)
Kussmaul’s Sign
Pulsus Paradoxus
an inspiratory systolic fall in arterial pressure >12 mmHg during normal breathing (check BP with inspiration) – 70-80% of patients
clinical presentation of cardiac tamponade (not included the associated)
Tachypnea / DOE
Air hunger
Anorexia
Fatigue
Dysphagia
Tachycardia
Hypotension
Signs of shock
Kussmaul’s Sign
Pulsus Paradoxus
Other associated s/s of cardiac tamponade include:
- Palpitations
- Low-grade fever (but can go as high as 104°)
- Dyspnea/tachypnea most common in large effusions and tamponade
- Pericardial friction rub
- Narrow pulse pressure
- Dry Cough/Hiccups
- Edema
- Cyanosis
- Varying degrees of consciousness
- Hepatomegaly and ascites
- Tachycardia and cardiac arrhythmias (PACs, PVCs)
ELECTRICAL ALTERNANS is pathognomonic of what dx?
- CARDIAC TAMPONADE
- Characterized by alternating levels of ECG voltage of the p wave, QRS complex, and T waves.
- This is the result of the heart “swinging” in a large effusion.
CXR of cardiac tamponade
- Not helpful in uncomplicated pericarditis and small effusions. May be normal.
- A flask-shaped, enlarged cardiac silhouette may be the first indication of a large pericardial effusion (200-250 mL of fluid accumulation) or cardiac tamponade.
what is the initial test of choice for cardiac tamponade/effusions
Transthoracic echo (TTE)
When checking for tamponade, we look for 3 things:
- RV Collapse
- LV Collapse
- Dilated IVC w/out inspiratory collapse
provides anatomic details of the entire pericardium due to its capacity in providing a wide field of view. Advantages include its capacity to detect pericardial calcifications.
what type of diagnostic eval for cardiac effusion/tamponade?
CT scan
provides anatomic details of the pericardium and heart without ionizing contrast or radiation. Sensitive for detecting pericardial effusion and loculated pericardial effusion and thickening. Limited use in patients with arrhythmias
what type of diagnostic eval for cardiac effusion/tamponade
MRI
Most pts with large effusions or any evidence of hemodynamic compromise, or with the following, require hospital admission: (s/s) (6)
- Fever (>38ºC [100.4ºF]) and leukocytosis
- Immunosuppressed
- Hx of therapy with V-K antagonists
- trauma
- Failure to respond within 7 d to NSAIDs
- Elevated cardiac troponin
management options for cardiac tampoande
- Pericardiocentesis
- Pericardial Fluid Analysis
- Pericardial Diodesis
- Pericardiotomy
- pericardial window
- pericardiectomy
- Removing fluid from the pericardium
- Diagnostic and therapeutic
- Complications include fatal cardiac laceration.
what is this cardiac tamponade management
Pericardiocentesis
indications for pericardiocentesis
- For effusions >250 mL
- effusions when size increases despite intensive dialysis for 10-14 days
- effusions with evidence of tamponade
- Analyze for RBCs, total protein, LDH level, adenosine deaminase activity, gram stain, acid-fast, fungal staining, cultures, cytology.
- Directly investigate for tuberculous bacilli and perform a cytologic study.
what type of cardiac effusion/tamponade management is this?
Pericardial Fluid Analysis
purulent or suppurative pericarditis will present with what type of pericardial fluid analysis
thin to creamy pus
pericardial fluid analysis reveals adhesions present between the pericardial membranes, which are thickened, which frequently result in bloody effusions.
what type of pericardial dz is this?
uremic pericarditis,
pericardial fluid is often clear with high protein and cholesterol levels and with few cells.
what type of pericardial dz?
hypothyroidism
Installation of chemical or other agents into the pericardial space
Act to cause sclerosis of the pericardium
Used for recurrent pericardial effusions
what is this pericardial dz management
Pericardial Diodesis
when to consider pericardiotomy
Consider (subxiphoid or percutaneous balloon) pericardiotomy for large effusions that do not resolve.
Incision into the pericardium
May be performed under local anesthesia and has a lower risk of complications than pericardiectomy.
what type of pericardial dz management?
pericardiotomy
Effective (90-97%)
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.
Pericardial Window
Can be performed with a balloon catheter.
The most effective surgical procedure for managing large effusions
Pericardiectomy
since Pericardiectomy requires general anesthesia and a thoracotomy, only consider if ?
pericardiotomy can’t be performed or has been unsuccessful.
Lowest associated risk of recurrent effusions. Failure rates proportional to the amount of pericardium removed.
what pericardial dz procedure is this?
Pericardiectomy
Inflammation of the pericardium can lead to a thickened, fibrotic, adherent pericardium
Constrictive Pericarditis
Constrictive Pericarditis restricts diastolic filling, which predominantly presents as ?
right heart failure
MCC of Constrictive Pericarditis in developing countries? developed?
- TB
- Radiation, cardiac surgeries and viral pericarditis MCC in developed countries
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 dx?
Constrictive Pericarditis
diagnostic eval for Constrictive Pericarditis
- Diagnosis is difficult to make initially
- Echo - thickened pericardium
- May show the RV/LV filling changes, especially with inspiration - CXR – heart may be normal size or enlarged
- Cardiac CT or MRI – may show pericardial thickening
- Cardiac cath
- Allows for the simultaneous measurement of intracardiac pressures in the RV and LV, during inspiration and expiration
- Confirmatory in most cases
management for constrictive pericarditis
- Diuresis - Loop diuretics, aldosterone antagonists
- Surgical pericardiectomy - recommended for patients unresponsive to diuretics
