pericardial heart disease

Question 1

What is the most common cause of Acute pericarditis?

Answer 1

Infection (90%, MC viral – Coxsackie)

Question 2

What are other causes of acute pericarditis?

Answer 2

• Idiopathic (prob postviral)
• Acute MI or Post MI syndrome (Dressler’s syndrome)
• Metastatic Neoplasm (lymphoma, breast, lung)
• Blunt Trauma
• Drug Induced
• Endocrine (Myxedema)
• Uremia (metabolic d/o) – d/t elevated BUN & metabolic acidosis
• Autoimmune d/o (SLE, rheum arthritis, Reiter syndrome)
• Iatrogenic (radiation therapy → cancer, cardiac surgery, catheter)
• Bacterial, Fungal, Parasitic (underdeveloped countries)

Question 3

Who is at risk of getting pericarditis?

Answer 3

20-50 yo, M > F

~ 5% Chest Pain complaints in the ER = acute pericarditis— why is this fact important?

Question 4

What is the clinical presentation of acute pericarditis?

Answer 4

• MC = severe chest pain that worsens with breathing (inspiration) & lying down
• Pain localized to the retrosternal & left precordial area radiating to trapezius ridge and neck
• Chest pain is positional: relieved w/ sitting up and leaning forward
• Pericardial friction rub: high pitched, heard along left sternal boarder (best heard w/ pt sitting up during expiration – closer to chest)
• Few days of low grade fever (100F), myalgias, malaise, weakness, anxiety, restlessness, dysphagia, sinus tachycardia

Question 5

what are complications with acute pericarditis?

Answer 5

cardiac tamponade (15%)
-pericardial effusion (any cause of acute pericarditis that can lead to exudation of fluid into pericardial space)

Question 6

How long is acute pericarditis

Answer 6

<6weeks inflammation

Question 7

How long is sub-acute pericarditis

Answer 7

6wks-6months

Question 8

How longs is chronic pericarditis

Answer 8

> 6months

Question 9

what is recurrent pericarditis

Answer 9

Intermittent (symptom free intervals)
Incessant (recurs w/ anti-inflammatory cessation) Effusive-constrictive pericarditis
Effusion in pericardial space with constriction by the thickened pericardium

Question 10

what are the types of pericardial effusions

Answer 10

fibrous
effusive
constrictive

Question 11

Fibrous pericarditis is classified as?

Answer 11

dry, no effusions

Question 12

Effusive pericarditis is classified as?

Answer 12

purulent exudate (serous)
hemorrhagic exudate (serosanguineous)

Question 13

what is constrictive pericarditis?

Answer 13

• Impedes diastolic filling
• Occurs after acute pericarditis —Can be a late complication of acute pericarditis
• Can lead to Tamponade

Question 14

what are the clinical pericardial heart disease? signs and symptoms?

Answer 14

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

Question 15

What will you pick up on exam for a person with pericardial disease?

Answer 15

Low grade fever, sinus tachycardia
Pericardial friction rub along left sternal boarder High pitched
Heard better sitting up/leaning forward at end of expiration/left sternal border
(85%) and are heard intermittently in those who do have one.

Question 16

what will you see on EKG testing

Answer 16

ST elevations, PR depressions
EKG changes due to epicardial (visceral pericardium) inflammation 
No Q waves
Q waves = infarction
ST elevation = ischemia/inflammation

Question 17

what will you see on an echocardiogram?

Answer 17

pericardial effusion

Assesses for tamponade and degree of chamber compressions

Question 18

what will you see on lab tests?

Answer 18

Serum troponin
-slightly elevated, will normalize after 1-2 weeks
Troponin: I/T if elevated can imply myocardial inflammation
Inflammatory process
-ESR
-CRP
Serum BUN
->60mg/dl
CBC
↑WBC w/ purulent exudate and infectious causes

Question 19

What are the chest pain characteristics that are more specific to heart disease?

Answer 19

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

Question 20

What will you see on a CXR with pericardial heart disease?

Answer 20

water bottle heart silhouette
CXR Can show possible cause: TB, cancer, fungus, PNA
200cc (7 oz) of fluid must accumulate before silhouette enlarges 2L

Question 21

what is pericardiocentesis used for?

Answer 21

Obtain exudate (effusion) for culture and histology
Biopsy pericardium for suspected metastasis or primary neoplasm

Question 22

What are the DDx’s you should be thinking of along with pericardial heart disease?

Answer 22

MI
-present Q wave, inverted Twaves, responds to NTG, CP no change with respiration, modest rise in CK, pain lasts minutes
PNA
-fever, cough, neg ECG, positive CXR
PE
-CP not positional in nature, no friction rub,
Pneumothorax
-pleuritic, non-positional CP. unilateral decreased BS, CXR pos for pneumothorax
Costochrondritis
-reproducible pain with costochondral palpation, negative ECG, CXR

Question 23

what is the 1st line treatment for pericardial heart Dz?

Answer 23

1st line: ASA (2-4g/day) or NSAIDS + colchicine–prevents fibrosis
1-2 weeks NSAIDs
3 months Colchicine
PPI

Question 24

What do you add to the treatment regiment if patients do not respond to NSAID?

Answer 24

Prednisone (40-80mg/day)
In pts w/o purulent bacterial exudate
Prednisone can increase recurrence
1-2 weeks

Question 25

How would you go about determining whether to give systemic antibiotics?

Answer 25

get paricardiocentesis After blood and pericardial effusion culture & sensitivities are obtained
Get ID consult
Give IV Vancomycin plus ceftriazone or gentamicin (one example)

Question 26

what is the purpose of a pericardiocentesis?

Answer 26

Decompression of ventricular pressure from pericardial effusion
Prevention of tamponade progression, death
Must decompress large effusion (can be purulent or malignant)

Question 27

When do you do a pericardiectomy?

Answer 27

For recurrent pericarditis
Constrictive pericarditis with adhesions
Resistant to medical treatment

Question 28

what is the admission criteria for a person with pericardial heart disease?

Answer 28

fever 38°C or 100°F

Question 29

What is a cardiac tamponade?

Answer 29

compression of the heart due to fluid accumulation within the pericardium

Question 30

what determines the complications of pericardial tamponade?

Answer 30

rate of effusion accumulation
pericardium expandability
-In myxedema, Uremia, malignancy– effusion accumulates slowly = chronic tamponade
May not be acutely symptomatic
Will see symptoms after 2Ls of fluid accumulation

Question 31

What is the pathophysiology of tamponade?

Answer 31

-All cardiac chambers are compressed due to ↑intrapericardial Pressure

Question 32

what is beck’s triad?

Answer 32

Hypotension
Distant to absent heart sounds
JVD

Question 33

what is the definition of pulsus paradoxus?

Answer 33

Abnormally large ↓ in SPB (>10 mmHg) with inspiration

Is a Consequence of ventricular interdependence during inspiration

Question 34

what causes pulsus paradoxus?

Answer 34

Right ventricle bulges into left ventricle during diastole (filling)
There’s ↓ left ventricular filling/EDV → ↓ stroke volume and ↓ SBP with inspiration

Question 35

Which pulses can be used to measure pulsus paradoxus?

Answer 35

Brachial, radial, femoral

Question 36

How is Pulsus paradoxus best measured?

Answer 36

Best to observe rise and fall of Pt’s chest while taking the BP

Question 37

how is pulsus paradoxus calculated?

Answer 37

• Feel radial pulse—if pulse amplitude decreases with inspiration (observe chest movements) suggestive of severe Pulsus Paradoxsus
• Calculate difference between 1st korotkoff SBP sound during expiration and when SBP is heard throughout the respiratory cycle.