Pericardial Heart Disease Flashcards
Categories of Pericardial Disease as per duration (4)
Acute = < 6 weeks inflammation
Sub-acute pericarditis (6 wks →6 mos)
Chronic pericarditis (>6 mos)
Constrictive
Effusive
Adhesive (non-constrictive)
Recurrent pericarditis
Intermittent (symptom free intervals)
Incessant (recurs w/ anti-inflammatory cessation) Effusive-constrictive pericarditis
Effusion in pericardial space with constriction by the thickened pericardium
Categories of Pericardial Disease as per pathology (3)
Fibrous
Dry, no effusions
Effusive Purulent exudate (serous) Hemorrhagic exudate (serosanguineous)
Constrictive pericarditis (Compressive Syndrome)
Most serious form
Impedes diastolic filling
Occurs after acute pericarditis
Can be a late complication of acute pericarditis
Can lead to Tamponade
Etiology of Pericarditis (2)
(90% viral or idiopathic) of acute pericarditis Infectious Other: Idiopathic (probably viral or autoimmune) Metastatic neoplasm Acute MI Post MI syndrome (Dressler’s Syndrome) Trauma (Blunt, penetrating, iatrogenic) Endocrine: Myxedema
Viral Causes of Pericarditis (6)
Coxsackie virus A, B Echo virus 8 Mumps Adenovirus hepatitis HIV
Bacterial Causes of Pericarditis (6)
Streptococcal Staphylococcal Meningococcal Hemophilus Chlamydia TB (Mycobacterium tuberculosis, tubercle bacillus) Treponema
Fungal and Parasitic Causes of Pericarditis
Fungal:
Candida
Histoplasmosis
Parasitic Entamoeba histolytica (anaerobic protozoan) Echinococcus granulosus (tape worms)
Epidemiology of Pericarditis
Age of onset
20-50
Men > women— why is this fact important?
~ 5% Chest Pain complaints in the ER = acute pericarditis— why is this fact important?
Signs/ Symptoms of Pericarditis
few days with low grade fever
Myalgias
Malaise, weakness
Anxiety, restlessness
dysphagia
Followed with sudden onset of severe anterior chest pain that worsens with breathing and lying down
On exam: Low grade fever, sinus tachycardia
Pericardial friction rub along left sternal boarder
Clinical Signs of Pericarditis
Pericardial friction rub:
High pitched
Heard better sitting up/leaning forward at end of expiration/left sternal border
Diagnostic Labs for Pericarditis
Diffuse/global ECG ST elevations, PR depressions
Echocardiogram: pericardial effusion
Lab tests: systemic inflammation: CRP, ESR, High WBC
Chest Pain characteristics (to help with the DDX) for Pericarditis
Not related to exertion
Does not respond to NTG (nitroglycerine)
Sharp, severe, constant, retro-sternal CP that radiates to the trapezius ridge (very characteristic)
Worst with inspiration and supine
Stabbing, pleuritic CP
Initial Workup of Pericarditis
Electrocardiogram (ECG/EKG)
Global ST elevation with PR depression
Represent inflammatory process
No Q waves
Serum troponin
Slightly elevated, will normalize after 1-2 wks
Inflammatory process:
Erythrocyte sedimentation rate
C-reactive protein
Serum BUN
> 60 mg/dL (uremia)
CBC
↑WBC w/ purulent exudate and infectious causes
Initial Imaging for Pericarditis
CXR
“Water bottle” heart silhouette
CXR Can show possible cause: TB, cancer, fungus, PNA
Echocardiogram
Shows pericardial effusion
Assesses for Tamponade and degree of chamber compression
Chest CT
Pericardiocentesis
Obtain exudate (effusion) for culture and histology
Biopsy pericardium for suspected metastasis or primary neoplasm
Ddx for Pericarditis
PNA
Fever, cough, neg ECG, positive CXR
Pneumothorax
Pleuritic, non-positional CP, unilateral decreased BS, CXR pos for pneumothorax
Costochrondritis
Reproducible pain w/ costochondral palpation, negative ECG/CXR
MI
Q waves, inverted T waves, responds to NTG, CP no change with respiration, CP lasts minutes vs. hrs → days, no friction rub, troponin and CK rise is modest with pericarditis.
PE
CP not positional in nature, no friction rub, ECG: S1Q3T3 pattern
Treatment for Acute Pericarditis
1st line: ASA (2-4g/day) or NSAIDS + colchicine–prevents fibrosis
1-2 weeks NSAIDs
3 months Colchicine
PPI
Prednisone (40-80mg/day)
In pts w/o purulent bacterial exudate
Prednisone can increase recurrence
1-2 weeks
Systemic antibiotics
After blood and pericardial effusion culture & sensitivities are obtained
Get ID consult
Fever and WBC (normalization are signs of good response to tx)
Give IV Vancomycin plus ceftriazone or gentamicin (one example)
Procedures used to Treat Acute Pericarditis
Pericardiocentesis (pericardial tap)
Decompression of ventricular pressure from pericardial effusion
Prevention of tamponade progression, death
Must decompress large effusion (can be purulent or malignant)
Pericardiectomy
For recurrent pericarditis
Constrictive pericarditis with adhesions
Resistant to medical treatment
When do we admit patients with Pericarial Heart Disease
Fever 38°C or 100°F
Leukocytosis (WBC > 11,000)
Cardiac tamponade
Pericardial effusion occupying > 20mm intrapericardial space
Immune suppressed state
Acute trauma
Failure to respond to initial 7 day NSAID tx
Elevated Cardiac Troponin level → Myopericarditis
Cardiac Tamponade
Compression of the heart due to fluid accumulation in the pericardium
Pathophysiology of Tamponade (5)
All cardiac chambers are compressed due to ↑intrapericardial Pressure
Normally the pericardium has fixed elasticity—the heart is more compressible
Once pericardial elastic limit is reached heart chambers compete w/ intrapericardial Pressure
↑ intrapericardial Volume/pressure: ↓cardiac chamber size: ↓ diastolic compliance : ↓ venous return (+JVD)
Decreased heart expandability increases ventricular interdependence
Beck’s Triad of Pericardial Tamponade
JVD
Hypotension
Distent to Absent Heart Sounds
Pulsus Paradoxus
Abnormally large ↓ in SPB (>10 mmHg) with inspiration
Is a Consequence of ventricular interdependence during inspiration
Right ventricle bulges into left ventricle during diastole (filling)
There’s ↓ left ventricular filling/EDV → ↓ stroke volume and ↓ SBP with inspiration
**EDV= end diastolic volume
Pulsus Paradoxus Clinically detectable:
Clinically detectable PP = moderate → severe Tamponade
There Paradox in PP is:
Pulses can be absent with audible heart sounds
PP is a consequence of ventricular interdependence: to fill one ventricular chamber, the other has to fill less.
Measuring Pulsus Paradoxus
Brachial, radial, femoral pulses can be used
Best to observe rise and fall of Pt’s chest while taking the BP
Calculate difference between 1st korotkoff SBP sound during expiration and when SBP is heard throughout the respiratory cycle.
Feel radial pulse—if pulse amplitude decreases with inspiration (observe chest movements) suggestive of severe Pulsus Paradoxsus
If there is doubt assessing for PP using the radial pulse and pt is symptomatic use SBP with a slow and deep breathing technique:
Measure SBP on quiet breathing—1st Korokoff is heard on Exp.
Increased cuff pressure 20 mmHg above SBP
Deflate cuff slowly and measure SBP during slow and deep inspiration/expiration cycles
Subtract SBP on quiet breathing from SBP during deep inspiration:
>10 mmHg = Pulsus Paradoxsus
