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Cardiovascular > Pericarditis > Flashcards

Pericarditis Flashcards

1
Q

What are the normal functions of the pericardium?

A
  • double-layer sac
  • exerts restraining force to prevent dilation of cardiac chambers during exercise and with hypervolemia
  • restricts anatomic position of the heart
  • decreases spread of infections from lungs/pleural cavities to heart
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2
Q

What is pericarditis?

A

Inflammation of pericardial sac

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3
Q

What are the possible causes of pericarditis?

A
  • Idiopathic
  • Infectious
  • Systemic diseases
  • Neoplasms
  • Drug toxicity
  • Myocardial injury
  • Pericardial injury
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4
Q

What etiology of pericarditis is a large portion of cases and likely viral, but undiagnosed?

A

Idiopathic

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5
Q

What is the most common cause of infectious pericarditis?

A

Viral

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6
Q

Which organisms are responsible for viral pericarditis?

A
  • Coxsackievirus
  • echovirus
  • influenza
  • varicella
  • hepatitis
  • HIV
  • measles
  • mumps
  • CMV
  • RSV
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7
Q

What is the epidemiology of viral pericarditis?

A

seasonal peaks, more common in males

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8
Q

This etiology of infectious pericarditis is rare and if occurs is likely an extension of pulmonary infections

A

Bacterial

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9
Q

This etiology of infectious pericarditis is rare in developed countries

A

TB

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10
Q

What systemic diseases can cause pericarditis?

A
  • Hypothyroidism
  • Inflammatory diseases (SLE, RA, Scleroderma, Sarcoidosis, IBD, polymyositis)
  • CKD
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11
Q

What type of pericarditis results from CKD?

A
  • uremic pericarditis
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12
Q

5-10% of pericarditis is due to ___what___. What type?

A

cancers
Lung CA and Breast CA = over half

Also, renal cell CA, leukemias, lymphomas, and malignant melanomas

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13
Q

How does cancer enter the pericardium?

A

via blood, lymph, or direct penetration

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14
Q

What medications can cause drug-induced pericarditis?

A
  • Penicillin and cromolyn sodium
  • Anthracycline chemo agents (doxyrubicin and cyclophophamide)
  • Procainamide, hydralazine, methyldopa, isoniazid
  • phenytoin
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15
Q

Why can penicillin and cromolyn sodium cause drug-induced pericarditis?

A

induce hypersenstivity reaction

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16
Q

Why can anthracycline chemo agents cause drug-induced pericarditis?

A
  • have direct cardiac toxicity
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17
Q

Why can procainamide, hydralazine, methyldopa, isoniazid cause drug-induced pericarditis?

A

Develop drug-induced lupus syndrome, leading to pericarditis

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18
Q

What can cause pericardial injury leading to pericarditis?

A
  • Invasive cardiac procedures
  • Post-pericardiotomy
  • Trauma
  • Radiation
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19
Q

What type of invasive cardiac procedures can cause pericarditis?

A
  • Pacemakers
  • ICDs
  • PCI
  • Ablations
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20
Q

What post-pericardiotomy procedures can cause pericarditis? Why?

A
  • CABG, valve replacements
  • Exaggerated immune response to injury
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21
Q

Who might be at higher risk for radiation induced pericarditis?

A
  • Those receiving high doses in areas surrounding heart
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22
Q

What can cause myocardial injury leading to pericarditis?

A
  • MI
  • Cardiotomy
  • Trauma
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23
Q

What sort of MI may cause pericarditis? How soon after MI can this occur?

A
  • Transmural MI; large MI
  • 2-5 days
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24
Q

What is Dressler Syndrome?

A
  • pericarditis 2 weeks after MI due to delayed autoimmune/inflammatory response
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25
Q

What are the 4 diagnostic features of pericarditis?

A
  1. Chest pain
  2. Pericardial friction rub
  3. EKG
  4. Pericardial effusion
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26
Q

What is the cardinal symptom of pericarditis?

A

Chest pain

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27
Q

Why might patients have chest pain due to pericarditis?

A

Due to heart rubbing against pericardium

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28
Q

What are characteristics of chest pain with pericarditis?

A
  • Precordial or retrosternal with referral to trapezius ridge, neck, left shoulder, or arm
  • Pleuritic quality, but can be sharp, dull, aching, burning, and/or pressing
  • Worse when lying flat, during swallowing or coughing, with body motion
  • Varying intensity
  • May be relieved by sitting and leaning forward; not affected by eating or exertion
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29
Q

In addition to chest pain, what is the clinical presentation of pericarditis?

A
  • Dyspnea, especially if effusion
  • Fever common
  • Pericardial friction rub
  • Other exam findings vary on cause as well as complications
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30
Q

What is the diagnostic evaluation of pericarditis?

A
  • Typically clinical
  • Labs directed at suspected cause:
  • Viral titers/panel
  • Cardiac enzymes: may be elevated if myocardium involved
  • Echocardiogram: OBTAIN ON ALL SUSPECTED PERICARDITIS PTS–> most likely normal, unless significant effusion
  • CBC: elevated WBC
  • BMP, thyroid function tests
  • ESR, CRP
  • EKG
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31
Q

What patterns will be present on EKG?

A
  • diffuse ST segment elevation progressing to T wave inversions
  • PR segment may be depressed

Inflammation of both ventricles (ST-T) changes and atria (PR changes)

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32
Q

What does the ST elevation in pericarditis look like?

A
  • Diffuse, in anterior and inferior precordial leads with reciprocal ST depression in aVR upward concavity morphology
  • Less prominent than in STEMI
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33
Q

What does PR depression in pericarditis look like?

A
  • Diffuse
  • Anterior and inferior precordial leads with reciprocal PR elevation in aVR in discordance with ST segment
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34
Q

What are characteristics of the T wave inversion in pericarditis?

A
  • Only seen on occasions
  • Less prominent than in STEMI
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35
Q

In stage I of pericarditis, what changes are seen on EKG?

A
  • ST segment elevation
  • PR segment depression
  • Reciprocal PR segment elevation and ST depression in aVR and occassionally V1
36
Q

In stage II of pericarditis, what changes are seen on the EKG?

A
  • Normalization of the ST and PR segments
37
Q

In stage III of pericarditis, what changes are seen on the EKG?

A
  • Widespread T wave inversions
38
Q

In stage IV of pericarditis, what changes are seen on the EKG?

A
  • Normalization of the T waves
39
Q

How is pericarditis diagnosed?

A
  • Chest x ray- typically normal, unless underlying malignancy or lung process identified or large effusion
  • CT or MRI may be necessary if malignancy is suspected
40
Q

What are the essentials of diagnosis of pericarditis?

A
  • Anterior pleuritic chest pain that is worse supine than upright
  • Pericardial rub
  • Fever common
  • ESR or inflammatory CRP usually elevated
  • ECG with diffuse ST segment elevation and associated PR depression
41
Q

What are the goals of management of pericarditis?

A
  • Determine inpatient or outpatient treatment
  • Treat symptoms/resolve the inflammation
  • Prevent recurrence
  • Address underlying cause if possible
42
Q

How is the pain and inflammation managed in pericarditis?

A
  • NSAIDs are first-line
  • Ibuprofen for 1 to 2 minutes, then taper over next 2 weeks
  • ASA in post-MI cases
43
Q

What factors should be indication to consider inpatient management?

A
  • Fever >100.4
  • Subacute onset
  • Immunosuppression
  • Trauma
  • Oral anticoagulation therapy
  • ASA or NSAID treatment failure
  • Myocarditis
  • Large pericardial effusion or tamponade
44
Q

How is recurrence of pericarditis prevented?

A
  • Colchicine is adjuvant therapy
  • Corticosteroids only if underlying disease process needs them or severe, refractory cases or if patients can’t tolerate NSAIDs or colchicine, prednisone
45
Q

How would you treat pericarditis if TB is the underlying cause?

A

Standard anti-TB drug regimen = treatment of choice

46
Q

How would you treat pericarditis if due to uremia with ESRD?

A
  • Dialysis
  • Chronic pericarditis with production of effusions common
  • NSAIDs help with pain and fever, but not process itself
47
Q

What is the pathophysiology of pericardial effusion/tamponade?

A
  • If the pericardial effusion gets big it puts pressure on the heart
  • Fluid and immune cells move into pericardial tissues and the layer becomes thicker
48
Q

What is the etiology of pericardial effusion?

A
  • same as pericarditis
  • aortic dissection/rupture can also lead to pericardial effusion or tamponade
49
Q

What is tamponade?

A
  • State of increased pressure
  • Characterized by elevated intrapericardial pressure, leading to decreased venous return and ventricular filling –> reduced CO
50
Q

What is the clinical presentation of pericardial effusion/tamponade?

A
  • If small, likely no symptoms or only symptoms of pericarditis
  • depends on size of effusion
  • if large, fatigue and shortness of breath
  • if hemodynamically significant (tamponade) - signs of cardiogenic shock
51
Q

What is Beck’s triad?

A

Clinical presentation of tamponade
* Distant/muffled heart sounds
* Hypotension
* Distended jugular veins

52
Q

What are specific signs that can clue you into cardiac tamponade?

A
  • Kussmaul’s sign
  • Pulsus paradoxus
53
Q

What is Kussmaul’s sign?

A

increase in JVP on inspiration instead of normal decrease

54
Q

What is pulsus parodoxus

A

Inspiratory systolic fall in arterial pressure >12 mmHg during normal breathing - 70-80% of patients

55
Q

What are signs of cardiac tamponade?

A
  • Tachypnea/dyspnea
  • Tachycardia/cardiac arrhythmias (PACs, PVCs)
  • Hypotension
  • Signs of shock
  • Palpitations
  • Low-grade fever
  • Pericardial friction rub
  • Narrow pulse pressure
  • Dry cough/hiccups
  • Edema
  • Cyanosis
  • Varying degrees of consciousness
  • Hepatomegaly and ascites
56
Q

What are symptoms of pericaridal effusion/cardiac tamponade?

A
  • air hunger
  • anorexia
  • fatigue
  • dysphagia
  • palpitations
57
Q

What is pathognomonic of cardiac tamponade?

A

Electrical alternans

57
Q

How do you diagnose pericardial effusion/cardiac tamponade?

A
  • ECG
  • CXR
  • Echo
  • CT scan
  • MRI
58
Q

Characterized by alternating levels of ECG voltage of the p wave, QRS complex, and T waves, results from swinging of heart in large effusion

A

Electrical alternans

59
Q

How will a effusion/cardiac tamponade present on CXR?

A
  • Uncomplicated pericarditis and small effusions may be normal
  • Flask shaped, enlarged cardiac silhouette may be first indication of large effusion or cardiac tamponade
60
Q

What is the initial test of choice for detecting pericardial effusions?

A

Transthoracic echo

61
Q

When checking for tamponade on an echo, what 3 things do we look for?

A
  • RV collapse
  • LV collapse
  • Dilated IVC w/out inspiratory collapse
62
Q

What are advantages of a CT for pericardial effusion/tamponade?

A
  • Can see anatomic details of entire pericardium
  • Capacity to detect pericardial calcifications
63
Q

What are considerations for MRI in pericardial effusion/tamponade?

A
  • Anatomic details of pericardium and heart without ionizing radiation or contrast
  • Sensitive for detecting pericardial effusion and loculated pericardial effusion and thickening
  • Limited use in patients with arrhythmias
64
Q

How is pericardial effusion/cardiac tamponade managed?

A
  • Small effusions, serial echocardiograms
  • Large effusions or evidence of hemodynamic compromise, hospital admission
  • Pericardiocentesis
  • Pericardial diodesis
  • Pericardiotomy
  • Pericardial window
  • Pericardiectomy
65
Q

What are indications for hospital admission in pericardial effusion/tamponade?

A
  • large effusion
  • hemodynamic compromise
  • fever >100.4 and leukocytosis
  • immunosuppressed state
  • history of therapy with V-K antagonists
  • acute trauma
  • failure to respond within seven days to NSAID therapy
  • Elevated cardiac troponin, which suggests myopericarditis
66
Q

Procedure where fluid is removed from the pericardium

A

Pericardiocentesis

67
Q

When would you perform a pericardiocentesis?

A
  • Effusions >250 mL
  • Effusions when size increases despite intensive dialysis for 10-14 days
  • Effusions with evidence of tamponade
68
Q

What are complications of pericardiocentesis?

A

Fatal cardiac laceration

69
Q

What can be analyzed on pericardial fluid analysis?

A
  • RBCs, total protein, LDH, adenosine deaminase activity, gram stain, scid fast, fungal staining, cultures, cytology
  • investigate for tuberculous bacilli and perform cytologic study
70
Q

What is the appearance of the fluid in purulent or suppurative pericarditis?

A

thin to creamy pus

71
Q

What is the appearance of effusions in uremic pericarditis?

A

bloody

adhesions present between membranes that are thickened

72
Q

what is the appearance of the pericardial fluid in hypothyroidism?

A

clear with high protein and cholesterol level and few cells

73
Q

installation of chemical or other agents into the pericardial space

A

pericardial diodesis

74
Q

What is the function of pericardial diodesis?

A
  • Used in recurrent pericardial effusions
  • Cause sclerosis of the pericardium
75
Q

Incision into the pericardium

A

Pericardiotomy

76
Q

When would a pericardiotomy be performed?

A

for large effusions that don’t resolve

lower risk of complications that pericardiectomy and effective

77
Q

surgical procedure to create a fistula from the pericardial space to the pleural cavity, allowing the effusion to drain out of the pericardial space into the chest cavity
can be performed with a balloon catheter

A

pericardial window

78
Q

removal of the pericardium
most effective surgical procedure for managing large effusions

A

pericardiectomy

79
Q

when is pericardiectomy considered?

A

requires thoracotomy and general anesthesia so only if pericardiotomy can’t be performed or is unsuccessful

80
Q

what is the pathophysiology of constrictive pericarditis?

A
  • Inflammation of pericardium –> thickened fibrotic, adherent pericardium
  • restricts diastolic filling –> right heart failure
81
Q

what are the most common causes of constrictive pericarditis?

A
  • TB in developing countries
  • Radiation, cardiac surgeries, viral pericarditis MC in developed
82
Q

What is the clinical presentation of constrictive pericarditis?

A
  • Progressive dyspnea
  • Fatigue
  • Weakness
  • Signs of right heart failure- edema, ascites, hepatic congestion
  • elevated JVP-Kussmaul sign
  • atrial fibrillation
83
Q

how is restrictive pericarditis diagnosed?

A
  • Echo- shows thickened pericardium, RV/LV filling changes, especially with inspiration
  • Chest xray- heart may be normal size or enlarged
  • Cardiac CT or MRI- may show pericardial thickening
  • Cardiac catheterization- confirmatory
84
Q

What is the benefit of cardiac catheterization in restrictive pericarditis?

A
  • Allows for simulataneous measurement of intracardiac pressures in the RV and LV, during inspiration and expiration
85
Q

How is restrictive pericarditis managed?

A
  • Diuresis with loop diuretics, aldosterone antagonists
  • Surgical pericardiectomy for patients unresponsive to diuretics

Cardiovascular (17 decks)

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