pericardial diseases

Question 1

What is the pericardium?

Answer 1

• tough double layered fibroserous sac that covers the heart
  pericardial sac has 2 layers:
• serous layer (inner layer) - parietal pericardium and the visceral pericardium (also called epicardium)
• fibrous layer (outermost layer)

Question 2

Fxns of the pericardium?

Answer 2

• stabilizes the heart in the mediastinum
• protects heart from infections
• lubricates the heart

Question 3

What is acute pericarditis?

causes?

Answer 3

• sudden inflammaton of the pericardium from a variety of conditions
• causes:
  infectious (most common)
  metastatic neoplasm (lung/breast)
• medication: procainamide and hydralazine
• bacterial
• systemic diseases (RA, lupus, hyperuremia)
• radiation
• dressler syndrome (post MI)

Question 4

Clinical findings on acute pericarditis?

Answer 4

• chest pain (Gets better when pt leans forward)
• dyspnea
• often febrile
• pericardial friction rub is characteristic

Question 5

Dx findings of acute pericarditis?

Answer 5

Run CBC, ESR, CXR, and echo

• leukocytosis
• eleveted ESR
• troponin (high, mimics MI, but won’t decrease like an MI, plateaus)
• CXR
• EKG: new widespread ST segment elevation, and PR depression in same leads (w/ both of these EKG can be more than 98% sensitive)

Question 6

Tx of acute pericarditis?

Answer 6

• tx underlying cause
• NSAID and aspirin
• colchicine (hyperuremia - gout)
• systemic corticosteroids:
  severe sxs, refractory, auto-immune disorders

Question 7

• major early complication of acute pericarditis?

Answer 7

• cardiac tamponade

Question 8

When should you hospitalize an acute pericarditis pt?

Answer 8

• fever and leukocytosis
• evidence of cardiac tamponade
• anticoag
• failure to respond within 7 days to NSAID therapy

Question 9

What is chronic or recurrent pericarditis?

Answer 9

• syndrome in which acute pericarditis recurs after the agent causing the acute attack has been tx or disappears
• usually occurs 6 weeks to 18 months after the acute attack
• most cases are autoimmune
• not associated with myocardial systolic dysfunction and HF sxs

Question 10

Clinical findings in chronic or recurrent pericarditis?

Answer 10

• pleuritic chest pain, +/- exertion

- dyspnea

Question 11

Predictor for recurrence of pericarditis?

Answer 11

• if glucocorticoid use initially in acute pericarditis

Question 12

Imaging for chronic pericarditis?

Answer 12

• EKG
• echo
• CXR
• labs - ESR and CRP will be elevated

Question 13

Tx for chronic or recurrent pericarditis?

Answer 13

• combo therapy: NSAIDs and colchicine
• glucocorticoids (taper off and sxs come back)
• activity restrictions
• pericardiectomy (last option - poor wound healing b/c of chronic steroid use)

Question 14

Pericardial effusions?

causes?

Answer 14

• abnormal accum of fluid in the pericardial sac
• causes:
  disturbance in equilibrium b/t production and reabsorption of pericardial fluid
• develops during any inflammatory pericardial disease
• 15-50 ml of fluid is usual amt of fluid within the pericardium
• the rate of fluid production will determine any hemodynamic effects

Question 15

4 types of pericardial effusions?

Answer 15

• transudative (CHF)
• exudative (inflammatory response - infection)
• hemorrhagic
• malignant

Question 16

Signs and sxs of pericardial effusion?

Answer 16

• +/- pain
• dyspnea
• cough
• pericardial rub may be present

Question 17

imaging for pericardial effusion?

Answer 17

• CXR: shows enlarged cardiac silhouette (water bottle heart)
• EKG: electrical alternans with sinus tachycardia
• echo: imaging of choice

Question 18

Tx of pericardial effusions?

Answer 18

• tx underlying cause
• small effusions can be followed
• with large effusions and tamponade drainage is done through pericardiocentesis
• pericardiectomy reqd for recurrences

Question 19

What is cardiac tamponade?

Answer 19

• increase pressure on the heart muscle when the pericardial space fills up with fluid faster than pericardial sac can stretch
• increase pressure causes elevation of intrapericardial pressure which restricts venous return and ventricular filling

Question 20

Etiology of cardiac tamponade?

Answer 20

• same as pericardial effusion (transudative, exudative, malignant, hemorrhagic)
• LV free wall rupture
• hemorrhagic pericarditis

Question 21

Signs and sxs of cardiac tamponade?

Answer 21

• dyspnea and cough common
• tachycardia
• tachypnea
• pulsus paradoxus
• becks triad:
  hypotension, JVD, muffled heart sounds

Question 22

Imaging for dx cardiac tamponade?

Answer 22

• EKG: electrical alternans
• echo: test of choice
• tx: urgent pericardiocentesis
• recurrent fluid may require paricardial window or partial pericardiectomy

Question 23

What is constrictive pericarditis?

Answer 23

• inflammation that leads to pericardium becoming fibrotic, thickened, and adherent and restricts diastolic fillings and produces chronically elevated venous pressures

Question 24

Causes of constrictive pericarditis?

Answer 24

• radiation
• cardiac surgery
• viral pericarditis
• idiopathic

Question 25

signs and sxs of constrictive pericarditis?

Answer 25

• slowly progressive dyspnea
• fatigue and weakness
• chronic edema
• elevated JVP
• kussmaul sign: on inhalation JV doesn’t diappear

Question 26

Imaging for constrictive pericarditis?

Answer 26

• CXR: egg shell around heart on lateral view
• Echo
  cath: assess pressures

Question 27

Tx of constrictive pericarditis?

Answer 27

• initial tx: diuretics
• surgical removal (pericardiectomy): morbidity and mortality are high (up to 15% - NSAIDs, diuretics, and steroids b/f surgery)

Question 28

What is a pericardiocentesis?

Answer 28

• pt positioned supine with head of bed raised at 30-60 degree angle
• usually done with US guidance
• 2 locations used: 5th-6th ICS at left sternal border at cardiac notch of left lung (parasternal approach), and infrasternal angle (subxiphoid approach)