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A- Resp and cardio > Pericarditis > Flashcards

Pericarditis Flashcards

1
Q

Diagnosis of pericardial disease

A

Over or equal to 2 of following 4
Pericardial chest pain
Pericardial rubs
New widespread ST elecation or PR depression ECG
Pericardial effusion - new or worsening

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2
Q

Supportive findings of pericarditis

A
  • Elevation of CRP/ESR/WCC
  • Evidence of pericardial inflammation on CT/CMR
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3
Q

What is recurrent pericarditis

A

Documented first episode + symptoms free 4-6 weeks
Normally within 18-24 months
15-30% recurrence rate

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4
Q

What is incessant pericarditis

A

> 4-6 weeks of symptoms
<3 months without remission
Chronic >3 months

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5
Q

Vrial causes of pericarditis

A

Viral - enteroviruses - coxsackie, e-coli
Herpes - EBV, CMV, HHV-6

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6
Q

Bacterial course of pericarditis

A

Common - Mycobacterium tuberculosis
Many other rare causes

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7
Q

Fungal causes of pericarditis

A

Histoplasma more likely immunocompetent
Aspergillus, blastomyces spp, candida - more likely in immunocompromised

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8
Q

Non infective causes of pericarditis

A

Autoimmune - common
Neoplastic
Primary tumours eg pericardial mesothlioma (rare)
Secondary metastatc tumours (lung, breast, lymphoma)
Metabolic
Trauma and iatrogenic
Drug related
other - amyloidosis, aortic dissection, pulmonary and arterial HPTN, chronic HF
Congenital partial and complete absence of pericardium

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9
Q

AI causes of pericarditis

A
  • Erythematosus
  • Sjrogen syndrome
  • Rheumatoid arthritis
  • scleroderma
  • Vasculitdes ie Eosinophilic granulomatosis w polyangitis or allergic granulomatosis (churg-strauss sydnrome)
  • Horton disease
  • Takayusus disease
  • Behcet syndrome
  • Sarcodiosis
  • Familial
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10
Q

Metabolic causes of pericarditis

A
  • Uraemia
  • Myxoedema
  • Anorexia nervosa
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11
Q

Trauma and iatrogenic causes of pericarditis

A

Early onset
Direct injusry - oesophageal perforation, penetrating thoracc injury
Indirect injury - eg radiation
Delayed onset - pericardial injury eg post MI syndrome, postpericardiotomy, PCI, pacemaker lead insertion, readio ablation

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12
Q

Drugs causing lupus like syndrome pericarditis

A
  • Procainamide
  • Hydralazine
  • Methyldopa
  • Isoniazid
  • Phenytoin
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13
Q

Antineoplastic drugs pericarditis

A

CM -> percardiopathy
Doxorubicin
Daunorubicin

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14
Q

Drugs causing pericarditis

A

Amiodraone
Methydergide
Mesalazine
Clozapine
Monoxidil
Dantrolene
Practolol
Phenylbutazone
THiazides
Streptomycin
Thiouracils
Streptokinae
P-aminosalicyclic acid
Sulfa drugs
Cyclosporinne
Bromocriptine
Several vaccines
GM-CSF
Anti TNF agents

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15
Q

Major predictors of poor prognosis in pericarditis

A

Fever >38 degrees
Subacute onset
Large pericardial effusion
Cardiac tamponade
Lack of resposne to aspirin or NSAIDs after at least one week of tehrapy

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16
Q

Minor pericarditis prognosis

A

Myopericarditis
Immunosupresson
Trauma
Oral anticoagulatn therapy

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17
Q

When admit to hospital w pericarditis

A

Underlying aetiology or at least one predictor of poor prognosis or major or minor risk factors

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18
Q

How manage pericarditis outside of hospital

A

Outpatient empiric anti inflammatories and short term follow up after 1 weeks assess response

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19
Q

Investigations with pericarditis

A

12 lead ECG
TTE
CXR
Infalm marer - CRP, ESR
MI markers - CK, troponin
ECHO
CMR

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20
Q

First line treatment pericarditis

A

Aspirin/NSAIDs + PPI
Colichine as adjunct

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21
Q

ECG changes pericarditis

A

ST elevation, PR depression in II, aVF
PR elevation in aVR

22
Q

Colichine MOA pericarditis

A
  • Improves response to above
  • Prevents recurrenes
  • halves recurrence rate
23
Q

2nd line treatment pericarditis

A

Low dose corticosteroids

24
Q

Maanagemnet of recurrent pericaridtis

A

1 - Aspirin or NSAID eg ibuprogen, indomethacin + colichine + exercise restriction
Decrease dose 250-500mg every 1-2 weeks
2 - low dose CCS
3 - IV immunoglobulin or anakinra or azathioprine
4 - pericardectomy

25
Q

Complications of percarditis

A

Cardiac tamponade
Constricitve pericarditis
More likely in bacterial

26
Q

What is cardiac tamponade

A

Life threatening slow or rapid compression of the heart due to pericardial accumulation of fluid, pus, blood, clots or gas

27
Q

Classification of cardiac tamponade

A

Acute or subacute or chronic >3 months
Size - mild <10mm, large >20mm
Circumferential or loculated

28
Q

What amount of pericardial fluid can cause tamponade

A

300-600ml

29
Q

Causes of cardiac tamponade

A
  • Pericarditis
  • TB
  • Iatrogenic
  • Trauma
  • Neoplasm/malignancy

Uncommon causes

  • Collagen vascular diseases
    • SLE
    • Rheumatoid arthritis
    • Scleroderma
  • Radiation induced
  • post MI
  • Uraemia
  • Aortic dissection
  • Bacterial infection
  • Pneumopericardium
30
Q

Characteristics of cardiac tamponade

A
  • Elevated intra cardiac pressures
  • Progressive limitation of ventricular diastolic filling
  • Reduced in CO
31
Q

Signs and symptoms of pericarditis

A
  • Dyspnoea + chest discomfort
  • Agitation + restlessness
  • Palpitation
  • Drowsiness or stupor
  • Decrease urine output
  • Weakness
  • Anorexia
  • Weight loss with chronic effusion
32
Q

Becks triad

A

Hypotension
Increasing JVP
Small, quiet heart

33
Q

Physical findings cardiac tamponade

A

Raised Central venous pressure
Tachypnoea
Tachycardia
Diminished heart sounds through fluid
Pericardial friction rub
Pulsus paradoxus

34
Q

What is pulsis paradox

A

inspiratory decline in systolic BP >10mmhg

-Increase venous return during inspiration

35
Q

Features of pericarditis on ECHO

A
  • Chamber collapse
  • Doppler signs increased ventricular interdependence
  • Inferior vena cava plethora
36
Q

Right atrial chamber collapse - inversion

A
  • R atrial chamber begins late diastole
  • Sensitive but not specific
  • Early diastole, goes for longer the worse the haemodynamics are
37
Q

Features of pericarditis on ECHO

A

Chamber collapse
Atria compressed in systole
IVC plethora - Dilated IVC >2.1cm with<50% resp change (elevated intrapericacrdial pressure)

38
Q

What are benefits of needle paricardiocentesis

A
  • Allows rapid drainage
  • Less invasive
  • Minimal preparation
39
Q

Complications of needle paracentesis

A

Laceratons of heart, coronaries or lungs
Incomplete drainage or recurrence
Not recommended for small effusions<1cm, loculation, adhesions or fibrinous standing

40
Q

Treatment for cardiac tamponade

A

Needle paracentesis
Surgical drainage
Percutaneous balloon pericardiotomy

41
Q

+ and negatives of surgical drainage for cardiac tamponade

A

More complete drainage
Less likely recurrence
Access for tissue biospy
Drain loculated effusions

Complciations - more pain, longer recovery, more morbidity

42
Q

When do Percutaneous balloon pericardiotomy

A
  • Large effusions esp malignant
  • Limited complication
  • Recurrence rare
43
Q

Medical therapy in cardiac tamponade

A

If hypotensive
For volume expansion, inotropic supprt
Avoidance of diuretics or vasodilators

44
Q

How to score for cardiac tamponade

A

Step 1 - score aetiology
2 - score clinical presentation
3 - score imagine
Cumulative score

45
Q

What score in aetiology of cardiac tamponade

A

Malignant disease - 2
TB - 2
Recent radiotherapy
Recent viral infection
Recurrent PE, previous pericardiocentesis
Chronic terminal renal failure
IMMUNODEFICIENCY or immunosupression
Hypo or hyperthyroidism or systemic AI disease = -1

46
Q

Clinical presenation scoring cardiac tamponade

A

Dyspnoea
Orthopneoa
Hypotnesion
Progressiec sinus tachycardua
Oliguria
Pulsus paradoxus >10 mmHg
Friction rub
Rapid worsenging symptoms
Slow evolution of disease = -1

47
Q

Imaging scoring for cardiac tamponade

A

Cardiomegaly ECHO
ECG changes
PE
IVC > 2.1cm
RV collapse
L atrial collapse
Swinging heart

48
Q

Urgent surgical management for cardiac tamponade causes

A

Type A aortic dissecction
Ventricular free wall rupture after acute MI
Severe recent chest trauma
Iatrogenic haemopericardium when bleeding cannot be controlled percutaneoisly

49
Q

Score for urgent pericardiocentesis vs postponing

A

> 6

50
Q
A

A- Resp and cardio (58 decks)

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