Pericardial Diseases - Exam 1 Flashcards
What is the role of the pericardium?
double-layered sac surrounding the heart that restricts the anatomic position of the heart. Decreases the spread of infections from the lungs and pleural cavities to the heart
a large portion of pericarditis causes are ______. What is the MC?
no identifiable cause
viral are the MC cause
When bacterial endocarditis does occur _____ is the likely culprit
extension of pulmonary infections
cancer pericarditis is either going to be _____ or ______. Why?
lung or breast
they both are in close proximity
name 4 pericardial injuries that can cause pericarditis
invasive cardiac procedures
post-pericardiotomy
trauma
radiation
**What is Dressler syndrome? What is the tx?
pericarditis that occurs 2 weeks after a MI due to an autoimmune/inflammatory response
usually self limiting
What are the 4 main diagnostic features of pericarditis?
chest pain
pericardial friction rub
EKG
pericardial effusion
**What is the cardinal symptom of pericarditis? Where? Is it pleuritic? What makes it worse? better?
Chest pain caused by the heart rubbing against the pericardium
Usually precordial or retrosternal with referral to the trapezius ridge, neck, left shoulder, or arm
PLEURITIC
worse: lying flat, swallowing, coughing, body movement
better: sitting up and leaning forward
What is the characteristic heart sound associated with pericarditis?
pericardial friction rub
What is a EKG finding that would point to pericarditis?
diffuse ST segment elevation (aka ST segment elevation everywhere NOT just in specific boxes that would indicate MI)
What is the diagnostic criteria for acute pericarditis?
need at least 2:
Typical chest pain - pleuritic, worse with lying down, improved with sitting/leaning forward
Pericardial friction rub
Characteristic ECG changes
New or worsening pericardial effusion
What is the tx for acute pericarditis? _____ should be used in post-MI cases. ________ is used in severe/refractory cases or when the first line agent is CI
Ibuprofen or Indomethacin for 14 days
+/- colchicine as adjuvant
ASA is preferred post-MI
Prednisone
Because the pericardium covers the ascending aorta and arch, _______ can also lead to a pericardial effusion/ tamponade
aortic dissection / rupture
What is cardiac tamponade? What does it depend on?
increased pressure around the heart
no specific amount of fluid but depends on the RATE of ACCUMULATION
What does cardiac tamponade lead to?
the right atria is usually the first to collapse due to increased pressure which leads to reduced cardiac output and potentially cardiogenic shock = medical emergency
What does the presentation of cardiac tamponade depend on? Give both options
presentation is based on the size of the effusion
small: asymptomatic or s/s of pericarditis
large: chest pain, fatigue, SOB
aka super bad cardiac tamponade will have s/s of cardiogenic shock
**What is Beck’s triad? What is it associated with?
Beck’s triad: classic presentation of cardiac tamponade
JVD
Muffled Heart Sounds
Hypotension
What is Kussmaul’s sign?
increase in JVP on inspiration (instead of the normal decrease)
cardiac tamponade
What is 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 2 highlighted s/s of pericardial effusion?
Pericardial friction rub
Narrow pulse pressure
plus look for all the s/s of cardiogenic shock
What is the initial test of choice to dx pericardial tamponade? What 3 things should you look for on said test?
Echo TTE
RV Collapse
LV Collapse
Dilated IVC w/out inspiratory collapse
**The CXR of cardiac tamponade will often have _______. What does it indicate?
water bottle heart
fluid accumulation around the heart
**What is the EKG finding associated with pericardial effusion? What is it a result of?
ELECTRICAL ALTERNANS is pathognomonic of 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
Why would you order a CT in pericardial effusion? What is an advantage?
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.
Why would you order a MRI in pericardial effusion? What type of pt is it NOT good for?
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 is the management for small effusions? What is considered small?
serial echos
Usually <1cm in size
What is the criteria for pericardial effusion that requires hospital admission?
large effusions >2cm
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
When would pericardiocentesis be a good management option?
For effusions >250 mL, effusions when size increases despite intensive dialysis for 10-14 days, or effusions with evidence of tamponade
considered diagnostic and therapeutic
What are the 4 pericardial effusion tx options?
Pericardial Diodesis
Pericardiotomy
Pericardial Window
Pericardiectomy
What is happening in Pericardial Diodesis (Sclerotherapy)?
Installation of chemical in the pericardial space causing sclerosis of the pericardium - essentially eliminates the space between the heart and the pericardium so fluid can no longer accumulate
What is happening in a Pericardiotomy?
Incision made into the pericardium. Effective (90-97%)
What is happening in 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.
What is happening in a pericardiectomy?
Removal of the pericardium itself. The most effective surgical procedure for managing large effusions, but since it requires general anesthesia and a thoracotomy, only consider if pericardiotomy can’t be performed or has been unsuccessful
What is constrictive pericarditis caused by?
Inflammation of the pericardium can lead to a thickened, fibrotic, adherent pericardium that restricts DIASTOLIC filling which will present as right sided heart failure
____ is the most common cause of constrictive pericarditis in developing countries. **What are the 3 MC causes in developed countries?
TB
Radiation
cardiac surgeries
viral pericarditis
How will constrictive pericarditis present? What phase of the cardiac cycle is most affected?
Progressive dyspnea, fatigue and weakness
Edema, ascites, hepatic congestion
Elevated JVP – Kussmaul sign
Atrial fibrillation is common
(presents like right sided heart failure)
DIASTOLIC function is most affected
constrictive pericarditis presents similarly to other heart conditions, need to order ______ to confirm diagnosis.
cardiac cath to measure pressures in the right and left ventricle during inspiration and expiration
What is the tx for constrictive pericarditis? What is that doesnt work?
Diuretics!! loop or aldosterone antagonists
Surgical pericardiectomy is recommended for patients unresponsive to diuretics
