Pericardial dz + Cardiac Trauma - STOELTING CH 11

Question 1

The pericardium is a _ sac covering the heart and a portion of the great vessels

Answer 1

fibroserous

Question 2

2 layers of pericardium:

Answer 2

serosa (inner)
fibrosa (outer)

Question 3

Serosa layer of pericardium contains 2 layers: a _ layer of epicardium and a _ layer.

Answer 3

visceral layer of epicardium and a parietal layer
-between these = pericardial cavity

Question 4

Space between the visceral and parietal layer of the pericardium is called the _ _ and normally contains _ - _ mL of pericardial fluid (plasma ultrafiltrate)

Answer 4

pericardial cavity
10-50mL

Question 5

Normal thickness of a pericardium is _ - _ mm

Answer 5

0.8-1.0mm

Question 6

Pericardial reflections around the great vessels create sinuses. Where are they located?
-U-shaped oblique sinus
-transverse sinus

Answer 6

U shaped/oblique = behind LA, IVC, and pulm veins

Transverse = between aorta and PA, and the “dome” of LA and SVC

Question 7

Lymph drainage of pericardial fluid occurs via: (4 lymph node sites)

Answer 7

-tracheal
-bronchial
-anterior mediastinal
-posterior mediastinal

Question 8

What is the source of the viscoelastic mechanical properties of the pericardium?

Answer 8

dense parallel arrays of collagen layers with short elastin fibers between them

Question 9

T/F Stiffness of pericardium is greater than that of the cardiac muscle

Answer 9

true
-allows equalization of ventricular compliances to maximize diastolic interaction

Question 10

2 different resistances to mechanical stress found in pericardium, which types of stress affect which layers/fibers
-small effusions
-large effusions

Answer 10

small = impact only elastin fibers

large = opposed by the resistance of rigid collagen fibers

Question 11

The pressure-volume curve of a pericardial effusion is _ -shaped

Answer 11

J
-either increases slowly/rapidly over time
-quick effusions reach limit of pericardial stretch despite less volume because less time to allow stretch to allow more volume
-slower effusions reach limit after more volume and time because compensatory mechanisms have more time to allow stretch

Question 12

Describe the concept of ventricular interdependence.

Answer 12

Negative intrathoracic pressure during inspiration INCREASES RV filling. The interventricular septum accommodates this extra filling and SHIFTS LEFT, impairing LV filling. This causes a transient DECREASE in CO and systemic BP.

-this is exaggerated when intrapericardial pressures are elevated and cause pulsus paradoxus-seen in tamponade

Question 13

Congenital partial pericardium absence is usually _ sided

Answer 13

left

Question 14

Most common congenital pericardial disorder is _ _

Answer 14

pericardial cysts

Question 15

Congenital pericardial cyst preferred treatment:

Answer 15

surgical excision via VATS
-high incidence of recurrence with only percutaneous drainage so surgical is best

Question 16

Congenital pericardial cyst
-s/s

Answer 16

asymptomatic or respiratory dyspnea, arrhythmias, infection, compression of surrounding structures

Question 17

Most common pericardial disorder

Answer 17

pericarditis

Question 18

T/F Pericarditis always is accompanied by pericardial effusions

Answer 18

false
-may/may not be

Question 19

Pericarditis is classified by _ and _

Answer 19

duration and recurrence

Question 20

Pericarditis classes
-acute
-incessant
-chronic
-reccurent

Answer 20

acute: last 2-4wks (mult etiologies, sometimes idiopathic)

incessant: last 1-3 months

chronic: >3 months

recurrent: recurrence after 4-6wks of symptom free period

Question 21

Pericarditis DX (needs 2/4 criteria):

Answer 21

-pleuritic cp
-pericardial friction rub
-diffuse ST-elevation or PR depression
-new/worsening pericardial effusion

Question 22

EKG changes
-pericarditis

Answer 22

diffuse ST elevation or PR depression

Question 23

Differential dx Pericarditis vs CAD
-EKG

Answer 23

Pericarditis = DIFFUSE ST elevation (CONCAVE UPWARD) or PR depression
-NO reciprocal ST depression

MI: ST elevation is CONVEX upward w RECIPROCAL depression
-NO PR depression

Question 24

What are the EKG changes seen in pericarditis caused by?

Answer 24

inflammation of superficial myocardium

Question 25

Differential dx Pericarditis vs CAD -s/s duration

Answer 25

pericarditis: hrs-days MI: mins-hrs

Question 26

Differential dx of Pericarditis vs CAD -pain + NTG -presence of friction rub

Answer 26

Pericarditis: -retrosternal, sharp/stabbing, RELIEF LEANING FORWARD, WORSE ON INSP -NTG NO HELP -friction rub PRESENT MI: -retrosternal pressure, no relief/worsening with posture or respiration changes -NTG helps -no friction rub

Question 27

Table 11.1 Etiologies of Pericarditis and Pericardial Effusions:

Answer 27

-Idiopathic -Infection (viral, bacterial, fungal) -Neoplastic (mesothelioma, sarcoma, or mets of CA, or radiation-induced) -Postcardiac Injury (trauma, postinfarction/Dressler syndrome, postpericardiotomy) -Med-induced (procainamide, hydralazine, isoniazid, cyclosporine) -Autoimmune (Churg-Strauss, Wegener, RA, sarcoidosis, scleroderma, ankylosing spond)

Question 28

Dx of pericarditis requires 2/4 main criteria but is also supported if other lab/dx are positive such as:

Answer 28

-CRP is elevated -ESR (erythrocyte sediment rate) is elevated -Leukocytosis -evidence of pericardial inflammation on CT/MRI -NOT elevated troponin I or T

Question 29

Table 11.3 Major factors assoc with severe illness in Acute Pericarditis (5):

Answer 29

-fever >38deg -tamponade -large effusion size (>20mm on TTE) -subacute onset -lack of response to NSAIDs

Question 30

Sometimes pericarditis can cause myocarditis which can elevate myocardial biomarkers. 2 different names whether LV function stays same or worsens:

Answer 30

Pericarditis + Myocarditis WITHOUT LV depression = MYOPERICARDITIS Pericarditis + Myocarditis + LV depression = PERIMYOCARDITIS -this is dumb

Question 31

TTE/TEE can help find complications of pericarditis:

Answer 31

-effusion -constrictive pericarditis -wall motion abnormalities

Question 32

T/F In a normal pericardium there is vascularization

Answer 32

False -pericarditis can cause NEOVASCULARIZATION found with CARDIAC MRI with LATE GAD ENHANCEMENT

Question 33

Pericardial inflammation > edema, thickening of the _ pericardium, and _ pericardial effusion

Answer 33

parietal exudative pericardial effusion

Question 34

Mainstay Tx Pericarditis:

Answer 34

NSAIDs (decreases inflammation + symptom relief) Colchicine (decreases inflammation, this alone may be enough) +/- Steroids (help but increase risk of relapse after DCed) +/- ILK-1, methotrexate, azathioprine, mycophenolate, IVIG +/- surgical pericardectomy if recurrent cp

Question 35

Surgical repair of pericarditis is appropriate if cp is recurrent, what procedure is this?

Answer 35

pericardectomy

Question 36

T/F Pt's with pericarditis are encouraged to continue physical activity to avoid formation of clots in the pericardial sac

Answer 36

False -advised to stop physical activity until lab markers return normal bc increased risk of sudden death

Question 37

Most common post-cardiac injury syndromes (3):

Answer 37

Postinfarction Pericarditis (Dressler's Syndrome) Postpericardiotomy Syndrome Traumatic Pericarditis (from PCI/EP cases)

Question 38

Postinfarction Pericarditis/Dressler's vs Postpericardotomy Syndrome

Answer 38

Dressler's: late postinfarction pericarditis 1-8wks after -often with effusion, cp can mimic postinfarction angina -tamponade RARE Postpericardotomy: after cardiac surg, presents as acute pericarditis -peds > adults -autoimmune component -HIGHER RISK tamponade

Question 39

**Unexplained fever, pleuritic cp, pericardial rub, and elevated inflammatory markers** in a patient who had a cardiac procedure should raise suspicion for:

Answer 39

Post-cardiac injury syndrome causing pericarditis

Question 40

Tx of post-cardiac injury syndromes:

Answer 40

NSAIDs + Colchicine BUT ARE LESS EFFECTIVE THAN ON OTHER KINDS OF PERICARDITIS -colchicine can help postpericardiotomy but often not without GI s/e