Pericardial Diseases (Newman and Nichols) Flashcards
What is the mechanism of pulsus paradoxus in pericardial temponade
pulse disappears during inspiration
- the inter ventricular septum bulges into the left ventricle (the walls of the heart cannot expand)
- this inc the LV pressure and dec EDV
SBP and pulse wave amplitude decrease during inspiration
need to wiki this: “abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration”
what happens to a healthy LV when it is filled during diastole?
(Diastolic function of the healthy heart)
water balloon:
elastin in LV allows the LV to expand with smow rises in volume and pressure
(abn heart = loss of compliance/elasticity)
What is the normal amt of serous fluid in pericardial sac?
15-20 mL
With a sudden inc in serous fluid to 200 mL will the pressure in pericardial space change?
no = enough elasticity
With a sudden inc in serous fluid to 200 - 300 mL will the pressure in pericardial space change?
yes, sharp rise in pressure
Will a slow increase in 2L of serous fluid cause an increase in the pressur of the pericardial space change?
no
What are common causes of pericardial effusion
viral myopericarditis (simultaneous infection of heart muscle and pericardial tissue)
metastatic malignancy (lung and breast)
autoimmune disease (lupus)
renal failure
bleeding (hemopericardium)** commonly considered a separate syndrome
What is the test you need to do in the pt that presents with acute pericarditis to determine if it mild or severe?
troponin
1/3 of pts with acute pericarditis it is elevated and therefore it s an acute myopericaditis (both heart muscle and pericardium affected) and needs to be hospitalized
What 2 most common cancers causing pericardial effusion
lung
breast
T of F: uremia causes pericarditis and pericardial effusion
T: something that the kidney is not getting rid of is causing the inflammation
How is pericardial effusion diagnoses?
ECG:”
shows as clear halo and can estimate size of effusion and determine if there is tamponade, a functional disturbance (this is describing a CXR)
(chest X-ray
EKG: dec voltage)
WHen is pericardiocentesis performed?
pericardiocentesis is low yield for diagnosis of pericardial effusion and reserved for cases when there is tamponade bc this is simultaneous a diagnosis and treatment
Describe plain chest x ray showing pericardial effusion? How can you differentiate this from cardiomegaly?
globular cardiac silhouette
do an ECHO**
Blue heart (gross appearance)
hemopericardium (what you see and tamponade is the functional syndrome/cause of death)
deoxygenated blood
black heart at autopsy
clotted blood within pericardium of hemopericardium
What is a hemopericardium?
a structual an anatomical pathologic finding that is rare but comonly fatal
What are the causes of a hemopericadium?
- cardiac rupture (from transmural MI)
- aortic dissection rupture
- chest trauma
- anticoagulation
- leukemia
What is the diff between hemopericadium and cardiac tamponade?
syndrome vs finding
percardial effusion or blood compressing the heart enought to impaired filling and pumping
tamponade
symptoms of sudden cardiac tamponade?
slow developing tamponade
confusion, agitation, dyspnea, collapse, arrest
symp of HF: fatigue, leg edema, dyspnea
What is Beck’s Triad? What does the presence of this signify?
presence of cardiac tamponade
- JVD
- muffled heart sounds
- hypotension
What is an exaggeration of normal decrease in blood pressure with inspiration > 10 mmHg systolic?
pulsus paradoxus
How is tamponade diagnosed?
diastolic collapse of right atrium and right ventricle (on ECHO)
swan-ganz right heart cathetierization to show an increased and equalized right atrial and left atrial pressures
What is the treatment of cardiac tamponade?
tap it (subxiphoid)
What is the difference between serous and fibrinous and purulent AND hemorrhagic pericarditis?
serous: smooth surface, usually with effusion of 50 to 200 mL of thin fluid with protein <50% of serum level, scant neutrophils, lymphocytes and macrophages
fibrinous: dry rough, shaggy,surface, more neutrophils, lymphocytes, and macrophages
purulent: red granular surface coated with pus, lots of subsurface neutrophils, up to 500 mL of exudate in pericardium
hemorrhagic: any of the above types with blood
dry, rough, an shaggy pericardium
fibrous
condensed fibrin
microscopic:
dense pink stuff on surface
fibrous
self limited, usually over 1-3 weeks
caused by coxsackie (grou B) or echovirus
viral pericarditis
How is viral pericarditis diagnosed?
anti-viral titers if at all but usually pts recover on their own
What is the diagnostic criteria for acute pericarditis?
any 2 of these:
- pericardial friction rub (L sternal border)
- EKG (widespread ST elevation in 8-12 leads, which is way more than in MI)
- pericardial effusion
- positional sharp chest pain (worse when lying down and gets better leaning forward)
What 2 bugs commonly cause acute pericarditis?
staph aureus
strep pneumonia
What is the pathogenesis of acute pericarditis due to pyogenic bacteria
1. extension of empyema (empyema = purulent infection of pleural space) 2. expension of mycocardial abscess 3. seeding of pre-existing effusion 4. hematogenous infection
autoimmune pericarditis occurs in __% of pts with lupus and RA as part of a ____
30
polyserousitis with simultaneous pleuritis and peritonitis
What are hemorrhagic pericarditis assc with
metastatic carcinoma
leukemia
TB
encasement of the heart om dense fibrous or fibrocalcific scar
constrictive pericarditis
Why is constrictive peritonitis problematic?
prevents hypertrophy or dilation (even when needed)
pathophys similar to tamponade!
Tx of constrictive pericarditis?
Cause?
strip it (surgery) previous purulent or TB pericarditis
In diastole, what determines ventricular pressure?
intrapericardial pressure
*in tamponade, all of the diastolic pressures in the chambers are equal
How does tamponade effect CO?
heart cannot fill –> dec EDV which dec CO
How is the RV affected during cardiac tamponade?
RV cannot expand correctly due to pressure; greater bulging of intraventricular septum into LV
between the RV and the tamponade pressure the LV (vol and) pressure decreases–cannot expand outward
Acute pericarditis affects more (men/women); A big sign is that CP is better when:
Upon auscultation, you’ll hear:
women
sitting up/leaning fwd
pericardial friction rub
Acute pericarditis can evolve to form
fibrinous adhesions, organization, fibrous adhesions
“constrictive pericarditis”
