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Cardiovascular System > Pericardial Diseases > Flashcards

Pericardial Diseases Flashcards

1
Q

Pericardium is composed of …

A

Two layers:

  1. Visceral pericardium
  2. Parietal pericardium
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2
Q

Describe how the visceral pericardium is composed:

A
  • Membrane composed of single layer mesothelial cells
  • Similar to pleural and peritoneal cavity
  • Adherent to the epicardial surface of the heart
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3
Q

Describe how the parietal pericardium is composed:

A
  • Fibrous layer 2mm in thickness
  • Contains collagen and elastic fibers
  • Collagen:
    1. Low levels of stretch ⇒ Wavy bundles
    2. High levels of stretch ⇒ Streight bundles
  • Reflects the mechanical characteristics of the pericardial tissue
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4
Q

The visceral pericardium reflects back near the origin of the _____ ______ and becomes the ______ ________.

  • How much serous fluid is in the pericardial space in a healthy individual?
A

The visceral pericardium reflects back near the origin of the great vessels and becomes the parietal pericardium.

  • Pericardial space
    • Contains ≈ 15 - 50ml serous fluid in a healthy individual
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5
Q

What stabilizes the pericardium?

A

Stabilized by ligamentous attachements

  1. Diaphragm
  2. Sternum
  3. Spine
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6
Q

Phrenic nerves are enveloped by _______ __________.

  • What happens if the phrenic nerve is irritated?
A

Phrenic nerves are enveloped by parietal pericardium.

  • Phrenic nerve irritation ⇒ hiccups
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7
Q

What are the major functions of the pericardium?

A
  • Maintains heart position
  • Lubrication of visceral and parietal layers
  • Barrier to infection
  • Prostaglandin secretion
    • Modulation of coronary vascular tone
  • Restraining effect on cardiac volume
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8
Q
  • What is the restraining effect of the pericardium?
    • How does the pericardium respond to increased cardiac volumes?
A
  1. Restraining effect on cardiac volume
    • Mechanical properties of pericardial tissue
    • Small reserve volume
    • Tensile strength similar to rubber
    • Normal cardiac volume
      • More elastic ⇒ stretches easily
    • When there is increased cardiac volumes:
      • Pericardial tissue becomes stiff ⇒ resistant to further stretch
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9
Q

How is the Pericardial Pressure Volume Curve practically significant in pericardial effusions?

A

Practical significance in pericardial effusions

  • Once critical volume of effusion is reached small additional amounts ⇒ large increase of intrapericardial pressure
  • Removal of small amount of fluid ⇒ significant improvement of pressure
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10
Q

Acute vs chronic cardiac dilatation

A
  • Chronic cardiac dilatation results in adaptations to accomodate increased cardiac volumes
  • Pericardial growth occurs in response to chronic stretch
  • Pressure volume curve shifts to the right with decreased slope
  • Slowly accumulating pericardial effusions can become very large before becoming symptomatic (Hypothyroidism)
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11
Q

What is the major cause of acute pericarditis?

A
  • Majority (80-90%) of cases “Idiopathic”
    • No specific etiology identified with routine diagnostic testing
    • Most acute “Idiopathic” cases are assumed to be viral in etiology
    • Routine testing for specific viral agents not done
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12
Q

What are other causes of acute pericarditis?

A
  1. Infectious
    • Viral (Echo/Coxsackie/Adenovirus, CMV, HIV)
    • Bacterial(Pneumococcus/Strep/staph/mycoplasma/haemophilus)
    • Myobacteria (MT/MAI)
  2. Radiation (Acute and chronic)
  3. Blunt and penetrating trauma
  4. Connective tissue disorders
    • SLE, RA, Systemic sclerosis
  5. Post MI, and Dressler syndrome
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13
Q

What is the classic presentation of acute pericarditis?

A
  • Chest pain
    • Almost always present
    • Usually moderate to severe in intensity
    • Better sitting forward, worse when lying down
    • Sharp, pleuritic like
    • Substernal, epigastric, left chest, trapezius muscle area (specific for pericarditis)
  • Can be associated with dyspnea, cough, hiccups, fever
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14
Q

Differential diagnosis of CP in pericarditis:

A
  1. Pneumonia with pleurisy (Pleuro-pericarditis)
  2. PE with infarction
  3. Costochondritis
  4. GERD
  5. Intraabdominal processes
  6. Aortic dissection
  7. Pneumothorax
  8. Herpes Zoster (Before skin lesions)
  9. Myocardial ischemia/infarction
    • Presenting manifestation of clinically silent MI
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15
Q

What can be found upon physical examination on a patient with acute pericarditis?

A
  • Uncomplicated acute pericarditis
  • Fever, tachycardia, anxiety (Not always present)
  • Pericardial friction rub
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16
Q

Describe the pericardial friction rub in acute pericarditis:

A
  • Contact between parietal and visceral
  • Usually three components
    • Ventricular Systole, diastole, atrial contraction
  • Best heard at left LSB, w/ patient leaning forward
  • Dynamic (Similar to ECG findings)
  • Disappearing/returning over short periods of time
  • Frequently exam when suspecting pericarditis without audible rub
  • One or two component rub can represent mumurs (Use Caution)
17
Q

What are the ECG findings in acute pericarditis?

A
  • ECG changes are dynamic (Like rub)
  • ST segment elevation
    • Diffuse (Not in leads AVR,V1)
    • Occasionally focal (Trauma and post-op)
    • ST segment concave
    • No reciprocal changes
  • Upright T waves
  • PR depression (Elevation in AVR)
    • PR depression may be only ECG finding
18
Q

What are additional ECG findings in acute pericariditis?

A
  1. Low voltage QRS
  2. Electrical alternans
    • Secondary to pericardial effusion
19
Q

What are some potential lab findings in acute pericarditis?

A
  1. Idiopathic “Viral” pericarditis
    • Mild elevation of WBC count with lymphocytosis
    • Mild elevation of ESR
  2. Consider Secondary Etiologies:
    • Significant WBC elevation with left shift
    • Anemia, elevated ESR (Connective tissue disorders)
    • Elevated ESR (Connective tissue disorders, TB)
20
Q

What can be found on CxR in complicated acute pericarditis?

A

Abnormal CXR findings consided 2ry disorders

  1. Pleural effusions
  2. Infilrates
  3. Mass lesions
  4. CHF
21
Q

Why is an echocardiogram used in a patient with acute pericarditis?

A
  • Not required for diagnosis and management of idiopathic pericarditis
  • Small otherwise clinically silent effusion not uncommon
  • Large effusion consider secondary disorder
  • LV function assessment in pt with myocarditis
  • Check for WMA if ischemia/MI suspected
22
Q

What is used to treat “idiopathic” acute pericarditis?

A
  • Uneventful recovery in 70% - 90% of patients
  1. Treatment with NSAIDS (Post MI use aspirin)
  2. Colchicine
    • With NSAIDS
    • Alternative to NSAIDS
    • Decreased incidence of recurrent pericarditis
    • Discontinuation rate 10%-15% (GI side effects)
  3. Steroids
    • Rapid response to treatment
    • Corticosteroids may encourage relapses (Avoid if possible)
23
Q

What does colchicine act on?

A
  • Inhibits the process of microtubule self-assembly
    • This takes place either in the mitotic spindle or in the interphase stage
  • Inhibits movement of intercellular granules and the secretion of various substances in leucocytes
  • Significant anti-inflammatory action
  • Colchicine has preferential concentration in leukocytes
  • Peak concentration of colchicine may be 16 times the peak concentration in plasma
24
Q

What was the conclusion of the COPE trial?

A

Conclusion of the COPE trial:

  • Colchicine + coventional therapy led to clinically important and statistically significant benefit over conventional treatment
    • decreasing the recurrence rate in patients with a first episode of acute pericarditis
  • Corticosteroid therapy given in the index of attack can favor the occurence of recurrences
25
Q

How is acute pericarditis diagnosed?

A

Two of the following criteria:

  1. Typical chest pain (sharp and pleuritic, improved by sittng up and leaning forward);
  2. Pericardial friction rub
  3. Suggestive changes of on ECG (widespread ST-segment elevation or PR depression)
  4. New or worsening pericardial effusion
26
Q

What is “incessant” pericarditis?

A

diagnosis of incessant pericarditis:

  • patients with persistent pericarditis

or

  • those with symptom-free intervals of less than 6 weeks duration
27
Q

**Specific Causes of Pericardial Disease: **
Noninflammatory Conditions

A
  • Hydropericardium is an accumulation of serous transudate in the pericardial space
    • Associated with congestive heart failure, hyponatremia or chronic kidney or liver diseases;
  • Hemopericardium is an accumulation of blood in the pericardiac sac
    • Trauma of either the heart or aorta
    • Myocardial rupture after acute MI
28
Q

How is HIV involved in pericardial disease?

A
  • More common pre-HAART
  • 20% of HIV patients develop pericardial involvement
  • Pericardial effusion most common cardiac manifestation of HIV infection
  • Seen in more advanced stages of the disease
    • Presence of pericardial effusion associated with X9 greater 6 month mortality (independed of CD4 count)
  • Most effusions are small, asymptomatic, and idiopathic
  • Generalized sero-effusive process (“Capillary leak” syndrome)
  • Large effusions usually secondary to:
    • Infection (MT, MAI, CMV, Cryptococcus)
    • Neoplasm (Kaposi sarcoma, lymphomas)
  • Treatment
    • Identification of underlying etiology

Cardiovascular System (35 decks)

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