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Clin Med - Cardio I > Pericardial Heart Dz and Tamponade > Flashcards

Pericardial Heart Dz and Tamponade Flashcards

1
Q

normal pericardium

A
  • involves parietal layer & visceral layer
  • 15-50mL of intrapericardial fluid
  • stabilize and restricts chamber dilatation
  • minimizes friction bw heart and pulmonary pleura, vessels
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2
Q

what systemic disorders may cause pericardial heart dz

A

infection (usually viral)
idiopathic
systemic (metastatic neoplasm ie. breast, lung; rheumatic fever, endocrine - myxedema)
trauma - s/p acute MI (Dressier’s syndrome)
cardiac surgery
mediastinal radiation
uremia

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3
Q

4 categories of pericardial dz

A
  1. acute 6mo): constrictive, effusive, adhesive

4. recurrent - intermittent, incessant = effusion in pericardial space with constriction by thickened pericardium

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4
Q

3 types of pericardial dz

A
  1. fibrous - dry, no effusions
  2. effusive - purulent exudate
  3. constrictive pericarditis - impededs diastolic filling, occurs after acute pericarditis, can lead to tamponade
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5
Q

etiology of pericardial heart dz

A 
infectious - 90% viral (coxsackie A&B, Echo virus, Mumps, adenovirus, hepatits, HIV)
idiopathic
metastatic neoplasm
acute MI
post MI syndrome
trauma
endocrine - myxedema
associated with metabolic disorder - uremia
autoimmune dz 
myocarditis
iatrogenic
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6
Q

what is the definition of pericardial heart dz

A

inflammation and effusion of the pericardium

-isolated dz or manifestation of a systemic disorder

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7
Q

bacterial causes of pericardial heart dz

A

strep, staph, meningococcal, hemophilus, chlamydia, TB, treponema

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8
Q

fungal cause of pericardial dz

A

candida

histoplasmosis

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9
Q

parasitic causes of pericardial heart dz

A

entamoeba histolytica

echinococcus granulosus

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10
Q

age of onset for pericardial heart dz

A

20-50 yo

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11
Q

men vs women for pericardial heart dz

A

men>women

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12
Q

what % of chest pain complaints in ER are acute pericarditis

A

5%

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13
Q

cardinal manifestations of acute pericarditis

A
  1. chest pain
  2. pericardial friction rub
  3. EKG changes
  4. pericardial effusion - with or without tamponade
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14
Q

clinical presentation of pericardial heart dz

A 
s/s:
few days + with low grade fever
myalgias
malaise
anxiety
dysphagia
sudden onset of severe anterior chest pain that worsens with breathing and lying down
exam: low grade fever, sinus tachycardia & pericardial friction rub along left sternal border
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15
Q

what is the pericardial friction rub caused by

-how is it heard better

A

friction bw visceral and parietal pericardial surfaces

  • scratching, high pitched
  • heard better sitting up/leaning forward at end of expiration/left sternal border/stethoscope held firmly against chest
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16
Q

diagnostic labs for pericardial heart dz

A

diffuse/global EKG ST elevations, PR depressions
echo - pericardial effusion
lab - systemic inflammation - CRP, ESR, incr WBC

17
Q

chest pain characteristics of pericardial dz

A

pain is postural: lying, coughing, swallowing – relieved by sitting up and leaning forward
not related to exertion
does not respond to NTG (nitroglycerine)
sharp,severe,constant, retro-sternal CP that radiates to the trapezius ridge
stabbing CP

18
Q

initial workup of pericardial dz

A

EKG - global ST elevation with PR depression
-represents inflammatory process
NO Q Waves

19
Q

workup of pericardial dz to differentiate from MI

A

serum troponin - slightly elevated, will normalize after 1-2wks
inflammatory process - ESR, CRP
serum BUN >60mg/dL uremia
CBC - incr WBC with purulent exudate and infectious causes

20
Q

imaging for pericardial dz workup

A
  1. CXR - water bottle heart silhoutte, can show possible cause (TB, fungus, PNA, cancer
  2. echo - shows pericardial effusion, assess for tamponade and degree of chamber compression
  3. chest ct
  4. pericardiocentesis - obtain exudate for culture and histology; biopsy pericardium for suspected metastasis or primary neoplasm
21
Q

first line tx for pericardial dz

A

ASA or NSAIDS + colchicine, prevents fibrosis and recurrence

2 weeks NSAIDS, 3 months colchicine, PPI

22
Q

other treatment for pericardial dz

A

prednisone in pts w/o purulent bacterial exudate (1-2 weeks)
systemic antibiotics - after blood and pericardial effusion culture , get ID consult, fever and WBC, give IV vanco plus cetriazone or gentamicin)

23
Q

complication of pericardial heart dz

A

acute pericarditis

24
Q

what is the treatment of acute pericarditis

A
  1. pericardiocentesis - decompression of ventricular pressure from pericardial effusion; prevention of tamponade progression (death), must decompress large effusion
  2. pericardiectomy - for recurrent pericarditis, constrictive pericarditis with adhesions, resistant to medical tx
25
Q

when to admit pt with pericardial heart dz

A
  1. fever 100 degrees
  2. WBC >11,000
  3. cardiac tamponade
  4. pericardial effusion occupying >20mm intrapericardial space
  5. immune suppressed state
  6. acute trauma
  7. failure to respond to initial 7 day NSAID tx
  8. elevated troponin level –> myopericarditis
26
Q

what is cardiac tamponade

A

compression of the heart due to fluid accumulation within the pericardium

27
Q

development of tamponade depends on

A
  1. rate of effusion accumulation
  2. pericardium expandability
    ex. in myxedema, uremia, malignancy - effusion accumulates slowly = chronic tamponade = gives time for pericardium to expand
28
Q

how much fluid accumulation will cause symptoms

A

2L

29
Q

pathophys of tamponade

A
  1. all cardiac chambers are compressed d/t increased intrapericardial pressure
  2. normally ther pericardium has fixed elasticity - the heart is therefore sujected to compression with a tamponade
  3. once pericardial elastic limit is reached heart chambers compete with intrapericardial pressure
  4. incr intrapericardial volume/pressure: decr cardiac chamber size: decr diastolic compliance: decr venous return = +JVD
30
Q

Beck’s triad of pericardial tamponade of clinical features

A
  1. JVD - most common
  2. HTN
  3. distant heart sounds
    other: tachycardia, tachypnea, hypotension with onset of shock
31
Q

what is pulsus paradoxus

A

abnormally large decrease in SBP (>10mmHg) with inspiration

  • consequence of ventricular interdependence during inspiration (to fill one ventricular chamber, the other has to fill less
  • RV bulges into left ventricle during diastole and inspiration
  • therse’s decr LV filling/EDV = decr SV and decr SBP with inspiration
32
Q

what does clinically detectable pulsus paradoxus suggest

A

moderate to severe tamponade

33
Q

what is the paradox in PP

A

pulses can be absent with audible heart sounds

34
Q

how to measure PP

A
  • feel radial pulse - if amplitude decreases with inspiration suggestive of severe PP
  • brachial radial femoral pulses can be used
  • using the SBP - best to observe rise and fall of pts chest while taking BP
35
Q

PP measurement with BP

A
  • proceed with usual BP procedure
  • deflate BP cuff slowly
  • note SBP on quiet breathing - when 1st Korokoff is heard on expiration (highest)
  • increased cuff pressure 20 mmHg above SBP
  • deflate cuff slowly and meaure SBP during slow and deep insp/expir cycles and note when sound are heard during inspir (should be lowest)
  • subtract SBP during expiration from SBP during inspiration = >10mmHg difference = PP
36
Q

tx of PP

A

hemodynamically stable with small cardiac effusion
-monitor: JVP, PP, serial echos
when tamponade is present
-pericardiocentesis

Clin Med - Cardio I (7 decks)

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