Pericardial Diseases (complete)

Question 1

What are the layers of the pericardium?

Answer 1

Outside to inside:

• Fibrous layer
• Parietal pericardium
• Pericardial cavity
• Visceral pericardium

Question 2

What are the common causes of acute pericarditis?

Answer 2

• Viral illness
• CT or autoimmune diseases
• Uremia
• Metastatic tumors

Question 3

What are the common presentations of acute pericarditis?

Answer 3

• Sudden onset chest pain (SEVERE) => sharp
• Chest varies w/ position and breathing => this is NOT the case w/ MI

MI pain is also pressurized than sharp

Question 4

How do you diagnose acute pericarditis?

Answer 4

• Chest pain varies w/ position, breathing
• Pericardial rub on cardiac exam (comes and goes)
• EKG => diffuse ST elevation
• ECHO => pericardial fluid

There is a response to anti-inflammatory agents (NSAIDs are preferred, also aspirin and colchicine)

Question 5

Where do you see diffuse ST elevation on an EKG?

Answer 5

It’s everywhere! at every lead!

• NOT an MI => you’d be dead by now
• think pericarditis

Question 6

What are the common causes of pericardial effusion?

Answer 6

• Viral/acute idiopathic pericarditis
• Metastatic malignancy
• Uremia
• Autoimmune disease
• Hypothyroidism

Now there’s fluid accumulation

Question 7

How is pericardial effusion best diagnosed?

Answer 7

ECHO

Question 8

Describe small pericardial effusions

Answer 8

• W/o high intrapericardial pressure may be asymptomatic

- happens w/ acute trauma (gun shots, stabs)

Question 9

Describe large pericardial effusions

Answer 9

• Has high intrapericardial pressures

- Causes cardiac tamponade

Question 10

What is cardiac tamponade?

Answer 10

• Heart is unable to fill appropriately
• Myocardial compression impairs diastolic filling
• Causes by rapidly accumulates moderate sized or large effusions

Question 11

Describe the clinical presentation of pericardial effusion with tamponade

Answer 11

• Decreased RV diastolic filling during inspiration
• Distended neck veins
• Inspiratory decrease in arterial pressure (15-20 mm drop in systolic pressure) => paradoxical pulse

Question 12

Why does the BP drop with pericardial tamponade?

Answer 12

• Free wall of RV is unable to expand with each inspiration (b/c of effusion)
• In order to accomodate for increase in blood flow => it pushes septum => LV has a decreased SV

Question 13

What medication do you not want to give to patients with pericardial tamponade?

Answer 13

Diuretics!

• In fact you may want to give them fluid
• A stab wound will already decrease the BP b/c of fluid loss => not enough blood being pumped
• You want to increase BP to ^ blood to the rest of the body
• Diuretics would cause the pt to go into shock

Question 14

What findings do you expect to see and not see in a chest Xray?

Answer 14

• Enlarged heart

- Non-congested lungs (you would see this only in MI w/ lungs vessels accommodating the heart)

Question 15

Describe the findings in an ECHO of a pt w/ pericardial tamponade

Answer 15

• Collapse of RA and RV at end-diastole

- Dilation of IVC (does not collapse during inspiration)

Question 16

What do you expect to see on an EKG of a pt/ with pericardial tamponade?

Answer 16

• Low QRS voltage
• Also sinus tachycardia
• Electrical alternans w/ sinus tachy (every other beat the QRS voltage decreases)

Question 17

Describe constrictive pericarditis

Answer 17

• Scarring or loss of elasticity of pericardium

- Impaired diastolic filling w/ NORMAL systolic function

Question 18

What are the causes of constructive pericarditis?

Answer 18

• Idiopathic
• After cardiac surgery
• Radiation
• Infectious (TB is common)

Question 19

Describe the clinical presentation of a pt w/ constructive pericarditis

Answer 19

• Elevated JV pressure
• Tachy (very little filling of heart chambers => decreased SV => ^ HR to maintain CO)
• Often w/ hepatomegaly, edema, ascites

Looks like they have chronic liver disease

Question 20

How do you diagnose constrictive pericarditis?

Answer 20

• Transthoracic echo may see pericardial thickening (maybe calcified)
• MRI or CT can see pericardial thickening
• Cardiac cath shows an early dip and plateau pattern (square root sign) during diastole
• Cardiac cath shows equalization of diastolic pressures in RV and LV

Question 21

Describe the “clinical points” of constrictive pericarditis

Answer 21

• Chronic disease => takes lots of time to develop
• Cardiac silhouette normal sized but encased by thickened pericardium
• Lungs not congested
• Mistaken for liver disease b/c of prolonged high venous pressure => hepatic enlargement and ascites

Question 22

What is the treatment of constrictive pericarditis?

Answer 22

Surgical stripping of pericardium

Question 23

What is Kussmaul’s sign?

Answer 23

rise in JVP on inspiration