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Cardio Part 2= Clin Med > Pericardial Heart Disease > Flashcards

Pericardial Heart Disease Flashcards

1
Q

Categories of Pericardial Disease as per duration (4)

A

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

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2
Q

Categories of Pericardial Disease as per pathology (3)

A

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

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3
Q

Etiology of Pericarditis (2)

A 
(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
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4
Q

Viral Causes of Pericarditis (6)

A 
Coxsackie virus A, B 
Echo virus 8
Mumps
Adenovirus
hepatitis
HIV
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5
Q

Bacterial Causes of Pericarditis (6)

A 
Streptococcal
Staphylococcal
Meningococcal
Hemophilus
Chlamydia
TB (Mycobacterium tuberculosis, tubercle bacillus)
Treponema
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6
Q

Fungal and Parasitic Causes of Pericarditis

A

Fungal:
Candida
Histoplasmosis

Parasitic
Entamoeba histolytica (anaerobic protozoan)
Echinococcus  granulosus (tape worms)
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7
Q

Epidemiology of Pericarditis

A

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?

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8
Q

Signs/ Symptoms of Pericarditis

A

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

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9
Q

Clinical Signs of Pericarditis

A

Pericardial friction rub:
High pitched
Heard better sitting up/leaning forward at end of expiration/left sternal border

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10
Q

Diagnostic Labs for Pericarditis

A

Diffuse/global ECG ST elevations, PR depressions
Echocardiogram: pericardial effusion
Lab tests: systemic inflammation: CRP, ESR, High WBC

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11
Q

Chest Pain characteristics (to help with the DDX) for Pericarditis

A

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

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12
Q

Initial Workup of Pericarditis

A

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

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13
Q

Initial Imaging for Pericarditis

A

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

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14
Q

Ddx for Pericarditis

A

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

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15
Q

Treatment for Acute Pericarditis

A

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)

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16
Q

Procedures used to Treat Acute Pericarditis

A

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

17
Q

When do we admit patients with Pericarial Heart Disease

A

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

18
Q

Cardiac Tamponade

A

Compression of the heart due to fluid accumulation in the pericardium

19
Q

Pathophysiology of Tamponade (5)

A

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

20
Q

Beck’s Triad of Pericardial Tamponade

A

JVD
Hypotension
Distent to Absent Heart Sounds

21
Q

Pulsus Paradoxus

A

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

22
Q

Pulsus Paradoxus Clinically detectable:

A

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.

23
Q

Measuring Pulsus Paradoxus

A

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

Cardio Part 2= Clin Med (6 decks)

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