Pericarditis

Question 1

Periicarditis?

Answer 1

Acute pericarditis is an inflammation to the pericardium.

Question 2

Causes of peri?

Answer 2

1- idopathic.
2- infection
Auatoamuune disease
Cardia surgery

Question 3

Clinical presentation of peri?

Answer 3

AP is diagnosed when at least two of the following criteria are met:
1. Characteristic Chest pain
2. Characteristic ECG changes
3. Pericardial Friction rub
4. New or worsening pericardial effusion

Question 4

What is Characteristic chest pain in peri?

Answer 4

Sharp.
Persistent not related to exertion.
Pleuritic, increases with respiration.
Positional relieved when the patient leans forward and made
worse in the supine position. Often radiates to the trapezius ridge.
and may be associated with a low grade fever or other
symptoms of viral infection.

Question 5

Friction rub is diastolic and systolic

Question 6

Physical exam and echo, ecg, chest x ray and blood test?

Answer 6

Physical : pericaridal rub
Ecg: diffuse st elevation and pr segemnt changes.
Echo : percardial effusion
Chest x ray: : cradiomegaly
Blood test: white blood cells! Esr , crp

Question 7

Dullness over left posterior lung field due to
compressive atelectasis from pericardial
effusion

Answer 7

Ewart’s sign ( in pericarditis)

Question 8

ECG changes in peri?

Answer 8

Diffuse ST-segment elevation (concave upward)

• PR-segment depression in lead II and PR elevation in
aVR early in the course of pericarditis in >60% of cases, with

Question 9

Diagnosis for peri?

Answer 9

1- Troponin may be very mildly elevated in 25% of patients usually associated with normal CKMB. When
troponin values are higher and without wall motion abnormalities, the diagnosis of myopericarditis.

2-CXR may reveal pleural disease, cardiomegaly, or even the classic “water bottle” heart when a large
effusion is present, although it is most often normal in AP

2-Echo is essential to detect pericardial effusion and tamponade, Pericardial effusion is reported in about
50-60% of cases of pericarditis, and it is usually mild (<10 mm)

Question 10

In dfficult cases?

Answer 10

difficult cases, CT can show the inflamed pericardium as contrast enhanced

Question 11

When you will say the patient has?

Answer 11

Recurrent pericarditis: in cases of New symptoms after a remission with a symptom-free interval of >4-6 weeks

Incessant pericarditis: In cases of prolonged symptoms without remission.

Chronic pericarditis: for patients with continued symptoms >3 months

Question 12

Which drug reduces the incidence of post pericardioctomy syndrome?

Answer 12

Colchicine

Question 13

Whencwe admit patient to hopital ( high risk)

Answer 13

• High fever (>38°C),
• Subacute onset
, • Large pericardial effusion,
• Tamponade,
• The use of anticoagulants( to avoid hemoragic peri)
, • Trauma, • Evidence of myocarditis • Immuno-suppression • Lack of response to anti-inflammatory therapy

Question 14

Treatment of peri?

Answer 14

1-NSAID ( high dose iburprofen or asa or indomethacin) for 2 to 4-week and taper after resolution of symptoms and CRP normalization, along with

Colchicine for 3 months.

Aspirin is favored in post–myocardial infarction pericarditis.

Question 15

Which of the following agents may contribute to an increased risk of recurrent pericarditis?

Answer 15

Corticostirod

Question 16

When we use cortcistirod in acute pri?

Answer 16

Contraindications to NSAID therapy,
Failure of NSAID therapy,
Recurrences not responding to NSAID therapy,
Systemic inflammatory disease on steroids
Pregnancy,
Renal failure,
Concomitant anticoagulant therapies

Question 17

therapeutic options to be considered after failure of triple anti-inflammatory therapy include?

Answer 17

1- Azathioprine,
2-IVIG,
3-and biological agents (the most common in clinical practice is Anakinra)

Question 18

How much do you know about Kineret (Anakinra)?

Answer 18

Anakinra, an Interleukin-1 antagonist, Derived from E coli, is especially indicated in patients with recurrent pericarditis:
Steroid dependence and not able to withdraw steroids,

Colchicine resistance (unable to control the disease with colchicine),

Evidence of systemic inflammation (e.g., fever, CRP elevation)

Question 19

Steps of treatmnt in peri?

Answer 19

Aspirin or NSAID plus colchicine first,
 Then if the patient is still not responding or has additional recurrences, change to
a corticosteroid plus colchicine.
 If additional therapy is necessary, triple therapy may be considered with aspirin or
an NSAID plus corticosteroid plus colchicine
 In patients on steroids, it is critical to use low to moderate doses (e.g.,
prednisone 0.2-0.5 mg/day or equivalent) for 4 weeks,
 Then slow tapering after symptom resolution and normalization of CRP

Question 20

What are the causes of peri effusion?

Answer 20

Likely to progress to cardiac tamponade:

 Neoplastic diseases
 Infections (i.e. viral: EBV, CMV enteroviruses, HIV, bacterial, especially tuberculosis)
 Iatrogenic hemopericardium  Post-traumatic pericardial effusion
 Post-cardiotomy syndrome
 Hemopericardium in aortic dissection and rupture of the heart after acute myocardial
infarction.
 Renal failure

Rarely progressing to cardiac tamponade
 Systemic autoimmune disease
 Hypo- or hyperthyroidism
 Early and late pericarditis (Dressler’s syndrome) in acute myocardial infarction
 Others: Chylopericardium

Question 21

What is dressler syndrome?

Answer 21

Peri due to late post MI

Question 22

Which causes that never progressive to cardiac temponade?

Answer 22

Pericardial transudates caused by heart failure or
pulmonary hypertension

 Pericardial transudates in the last trimester of normal
pregnancy

Question 23

What is temponade?

Answer 23

Tamponade is a life-threatening cause of cardiogenic shock that may
develop acutely or chronically

Question 24

Why The rate of pericardial fluid accumulation is critical for the clinical
presentation

Answer 24

 If pericardial fluid is quickly accumulating, even less than 250 ml,
may cause acute cardiac tamponade “surgical tamponade” within
few minutes.

 Conversely, a slowly accumulating pericardial fluid may allow the
collection of 1000-1500 ml within days or weeks before
development of cardiac tamponade “medical tamponade

Question 25

What are the symptoms of cardiac temponade?

Answer 25

Signs and Symptoms
• tachycardia, hypotension, increased JVP
• tachypnea, dyspnea, shock, mufed heart sounds
• pulsus paradoxus (inspiratory fall in sBP >10 mmHg during quiet breathing)
• JVP “x” descent only, blunted “y” descent
• hepatic congestion/peripheral edema

Question 26

How to treat cardiac temonade?

Answer 26

pericardiocentesis recommended

Question 27

What to find in echo for cardaic temopnade?

Answer 27

pericardial efusion (size, location, hemodynamic impact),
swinging of the heart,

Question 28

What is the beck’s triad?

Answer 28

Found in temponade which are
1- high JVP.
2- hypotensiom.
3- muffled heart sound ( distent heart sound)

Question 29

Investigation pf cardiac temponade?

Answer 29

Ecg: swinging heart
Cxr: icreass cardia silhoutette
Echo:collapse of RA/ RV

Question 30

How to great peri effusion?

Answer 30

• Patients diagnosed with a large pericardial effusion and minimal or no evidence of hemodynamic
compromise may be treated conservatively with:

• Careful hemodynamic monitoring, • fluid resuscitation in an effort • serial echo, • avoidance of diuretics and vasodilators, • and therapy aimed at the underlying cause of the pericardial effusion. • Mechanical ventilation should be avoided whenever possible.

Question 31

What is Constrictive Pericarditis?

Answer 31

loss of pericardial elasticity caused by granulation tissue formation; leads to restricted ventricular
flling

Question 32

Signs and symptoms of cp?

Answer 32

• dyspnea, fatigue, palpitations
• abdominal pain
• may mimic CHF (especially right-sided HF)
■ venous congestion, ascites, hepatosplenomegaly, edema, pleural efusions
• increased JVP, Kussmaul’s sign (paradoxical increase in JVP with inspiration), Friedreich’s sign
(prominent “y” descent)

Question 33

Invitsagtiom of choice in cp?

Answer 33

Echo: pericardial thickening, calcifcation ± characteristic echo-Doppler fndings (Note:
CMR is discouraged if patient is hemodynamically impaired)

Question 34

How to treat cp?

Answer 34

surgery (pericardiectomy): mainstay treatment for chronic, permanent constrictive pericarditis •

medical therapy: can be used in 3 situations
1. for specifc pathologies/etiologies (e.g. TB) 2. for transient constriction that is temporarily caused by pericarditis, or new constriction
diagnosis with evidence of infammation of the pericardium (use anti-infammatories) 3. supportive when high/prohibitive surgical risk (goal is to relieve congestive symptoms diuretics,
salt restriction)