Pericarditis 11-24 (1) Flashcards
(124 cards)
1
Q
UW pericarditis.
Iatrogenic? 4
A
Surgery, trauma, radiation, drug related
2
Q
UW pericarditis.
Infection? 2
A
Viral (MOST COMMON) ir kitas most common yra idiopathic, bet testuose buvo virusas
Bacteria
3
Q
UW pericarditis.
Connective tissue disease? 2
A
Rheumatoid arthritis, systemic lupus erythematosus
4
Q
UW pericarditis.
Cardiac? 2
A
POST MI:
Early: peri-infarction pericarditis (2-4 days)
Late: Dressler syndrome (post-MI-pericarditis), usually 1-6 weeks after MI
5
Q
UW pericarditis. Uremic 2? BUN level
A
Acute or chronic renal failure
Serum BUN > 60 mg/dl, but degree of pericarditis does not always correlate with degree of elevation
6
Q
UW Acute pericarditis.
malignancy?
A
Can be due to cancer (lung and breast, Hodgkin lymphoma) or treatment (radiation, chemotherapy)
7
Q
UW pericarditis Presentation?
3 symptoms
A
Pleuritic chest pain
Fever
Triphasic pericardial frictions rub head at the left sternal border.
8
Q
UW pericarditis Presentation.
What is pleuritic chest pain, definition?
A
Radiates posteriorly to the BILATERAL trapezius ridges (lower aspect of the bilateral scapulae)
9
Q
UW Pericarditis presentation.
Triphasic pericardial friction rub is heard in what cycles?
HIGHLY SPECIFIC
A
i. Atrial systole
ii. Ventricular systole
iii. Early ventricular diastole
10
Q
UW Pericarditis diagnosis? 2
A
ECG, Cardioecho
11
Q
UW pericarditis.
2 ECG changes?
A
- Diffuse PR depression
- Diffuse ST elevation –> eventually evolves to diffuse T wave inversion
12
Q
UW pericarditis. ECG.
Why PR depression?
A
due to inflammation of atrial myocardium
13
Q
UW pericarditis. ECG.
Why ST elevation?
A
due to inflammation of ventricular myocardium
14
Q
UW. What major complication due to pericarditis?
A
Cardiac tamponade –> clear lungs, present pulsus paradoxus
15
Q
UW. What pain and temp. in pericarditis?
A
Pleuritic chest pain (decr. when sitting up) +/- fever
16
Q
UW. Treatment. 3 group medications?
A
NSAIDS (first line)
Colchicine
Corticosteroids
17
Q
UW. Medications.
Which decreases rate of recurrent pericarditis?
A
Colchicine
18
Q
UW. Pericarditis medications. In what 2 cases give corticosteroids?
A
- In patients with contraindications to NSAIDs (eg, renal insufficiency)
- In patients who do not respond to NSAIDs
19
Q
UW. Pericarditis. When avoid NSAIDS and corticosteroids? why?
A
Pericarditis occurring within 7 days of MI should not be treated with NSAIDs (other than aspirin) or corticosteroids. This is because it leads to impairment of scar formation
which increases risk of free wall rupture
20
Q
UW. Pericarditis. What to give instead of NSAIDS and corticosteroids?
A
i. We can give aspirin and colchicine in these cases
ii. Aspirin can also be given in patients who need concomitant antiplatelet therapy
21
Q
UW. Pericarditis.
How present costochondritis (differential)?
A
i. It is an inflammation of the parasternal cartilage
ii. Patients present with chest discomfort that is worse with movement and
reproducible with chest palpation
22
Q
UW. Pericarditis. What 2 differentials?
A
Costochondritis, viral pleurisy
23
Q
UW. Pericarditis.
How present viral pleurisy (differential)?
A
i. Pleural rub is differentiated from pericardial friction rub by disappearance during breath holding
24
Q
UW. CONSTRICTIVE PERICARDITIS. Definition/cause?
A
It occurs as a result of scarring and subsequent loss of normal elasticity of the pericardial sac
(due to fibrosis) with obliteration of the pericardial space
25
UW. CONSTRICTIVE PERICARDITIS.
Etiology? 5
a. Idiopathic or viral (most common cause in USA)
b. Cardiac surgery
c. Radiation therapy
d. TB (most common cause in endemic areas)
e. Uremia
26
UW. CONSTRICTIVE PERICARDITIS.
In what pathology is very common? when occur?
It is common in survivors of Hodgkin Lymphoma due to mediastinal irradiation and/or
anthracycline therapy
It presents 10-20 years after Hodgkin lymphoma treatment
27
UW. CONSTRICTIVE PERICARDITIS.
Features? 7
Right heart failure (Perif. edema), Ascites, incr. JVP
Pulsus paradoxus
Kussmaul’s sign (lack of decrease, or increase in JVP on inspiration)
Pericardial knock (mid-diastolic sound, not murmur)
Cardiac cirrhosis
Hypoalbuminemia (Due to protein-losing enteropathy (likely from intestinal lymphangiectasia in the
setting of incr. systemic venous pressures).
Fatigue and dyspnea on exertion
28
UW. CONSTRICTIVE PERICARDITIS.
Diagnostics?2
Chest radiography --> Pericardial calcifications
Echocardiography is confirmatory --> pericardial thickness, abnormal septal motion, Biatrial enlargemen
29
UW. CONSTRICTIVE PERICARDITIS.
Treatment? 2
a. Diuretics (temporary relief)
b. Pericardiectomy is the definite treatment
30
UW. CONSTRICTIVE PERICARDITIS.
ECG?
Nonspecific OR show atrial fibrillation or low woltage QRS complex
31
UW. CONSTRICTIVE PERICARDITIS.
Jugular venous pressure curve?
Jugular venous pulse tracing shows prominent x & y descents
32
ESC. acute pericarditis. typical hallmark?
Widespread ST-segment elevation has been reported as a typical hallmark sign of acute pericarditis
33
ESC. how does the chest pain improves in pericarditis?
Shest pain (.85–90% of cases)—typically sharp and pleuritic, improved by sitting up and leaning forward.
34
ESC. where is best heard pericardial friction rub?
A superficial scratchy or squeaking sound best heard with the diaphragm of the stethoscope over the left sternal border.
35
ESC. what other symptoms in acute pericarditis?
Additional signs and symptoms may be present according to the underlying aetiology or systemic disease (i.e. signs and symptoms of systemic infection such as fever and leucocytosis, or systemic inflammatory disease or cancer)
36
ESC. blood changes in acute pericarditis?
incr. CRB, ESR and WBC
37
ESC. when is present incr. troponine or CK?
Patients with concomitant myocarditis may present
with an elevation of markers of myocardial injury [i.e. creatine kinase (CK), troponin].
38
ESC. First line acute pericarditis treatment?
Aspirin or NSAIDs + gastroprotection
39
ESC. what adjunct recommended to primary treatment? why?
Colchicine as an adjunct to aspirin/NSAID therapy (at low, weight-adjusted doses to improve the response to medical therapy and prevent recurrences).
40
ESC. are corticosteroids recommended as first line?
NOT RECOMMENDED
Low-dose corticosteroids should be considered for acute pericarditis in cases of contraindication/failure of aspirin/ NSAIDs and colchicine, and when an infectious cause has been excluded, or when there is a specific indication such as autoimmune disease.
41
ESC. how to guide treatment effect?
Serum CRP should be CONSIDERED to guide the treatment length and assess the response to therapy
42
ESC. non pharmacologic treatment?
Non-pharmacologic: Exercise restriction should be considered for non-athletes with acute pericarditis until resolution of symptoms and normalization of CRP, ECG and echocardiogram.
43
UW. What dysfunction in CONSTRICTIVE PERICARDITIS?
Diastolic dysfunction
44
UW. What heart findings mostly in constrictive pericarditis?
right heart
45
UW pericarditis. What differentiation in patient with left HF?
constrictive vs restrictive
46
UW. Constrictive pericarditis. pericardiectomy for what?
Pericardiectomy is the definite treatment FOR CHRONIC PERMANENT CONSTRICTION.
47
ESC. constrictive pericarditis. 4 recommended diagnostics?
Cardio echo, chest x-ray
CT/cardio MRT - second-level imaging techniques to assess calcifications (CT), pericardial thickness, degree and extension of pericardial involvement.
Cardiac catheterization is indicated when non-invasive diagnostic methods do not provide a definite diagnosis of constriction
48
ESC. constrictive pericarditis 3 step management?
1 st. – treat specific etiology
2 nd – anti-inflammatory
3 rd - supportive and aimed at controlling symptoms of congestion in advanced cases and when surgery is contraindicated or at high risk
49
ESC. Viral pericarditis. reasons in developed countries?
viral infections or are autoreactive.
50
ESC. What most common in USA and what in developing?
Viral/idiopathic in USA
Tuberculous pericarditis is the most common form all over the world and the most common cause of pericardial diseases in developing countries.
50
ESC. Bacterial --> TBC pericarditis. in what countries?
Uncommon in developed.
Occurs in developing countries.
51
ESC. Viral pericarditis. Treatment?
Often self-limiting disease that responds well to a short course of treatment with NSAIDs, with the adjunct of colchicine, especially for prevention of recurrences.
Corticosteroids are not recommended.
52
ESC. Bacterial --> TBC pericarditis.
TB causes clinically significant pericardial effusion in >90% of HIV-infected
.
53
ESC. Bacterial --> TBC pericarditis. diagnostics?
1. chest X ray (we will detect pulmonary TB),
2. cardio echo (pericardial effusions, porridge like fluid, but its non-specific).
3. CT scan and/or MRI of the chest are alternative imaging modalities.
4. Culture of sputum, gastric aspirate, and/or urine for Mycobacterium tuberculosis (M. tuberculosis) should be considered in all patients.
5. Scalene lymph node biopsy if pericardial fluid is not accessible and lymphadenopathy present. Tuberculin skin test is not helpful.
6. If pericardial fluid is not accessible, a diagnostic score of ≥6 based on the following criteria is highly suggestive of tuberculous pericarditis in people living in endemic areas: fever (1), night sweats (1), weight loss (2), globulin level >40 g/L (3) and peripheral leucocyte count <10 x 10^9 /L. (3).
54
ESC. Bacterial --> TBC pericarditis. when indicated pericardiocenthesis?
Therapeutic pericardiocentesis is absolutely indicated in the presence of cardiac tamponade.
Diagnostic pericardiocentesis should be considered in all patients with suspected tuberculous pericarditis.
55
ESC. Bacterial --> TBC pericarditis. when indicated ab treatment?
Tuberculosis endemic in the population: trial of empiric antituberculosis chemotherapy is recommended for exudative pericardial effusion, after excluding other causes such as malignancy, uraemia, trauma, purulent pericarditis, and auto-immune diseases.
Tuberculosis not endemic in the population: when systematic investigation fails to yield a diagnosis of tuberculous pericarditis, there is no justification for starting antituberculosis treatment empirically.
56
ESC. Bacterial --> purulent pericarditis. most common m/os?
staphylococci, streptococci and pneumococci, while the predominant associated lesions were empyema (50%) or pneumonia (33%).
57
ESC. Bacterial --> purulent pericarditis. most common m/os post thoracic surgery or immunocompromised?
Staphylococcus aureus (30%) and fungi (20%) are more common.
58
ESC. Bacterial --> purulent pericarditis.
May present anaerobes originating from oropharynx.
.
59
ESC. Bacterial --> purulent pericarditis.
Seeding may be haematogenous or by contiguous spread from the retropharyngeal space, cardiac valves and below the diaphragm.
.
60
ESC. Bacterial --> purulent pericarditis. How generally presents?
Generally manifested as a serious febrile disease. The underlying sepsis may predominate the illness.
61
ESC. Bacterial --> purulent pericarditis. Urgent treatment?
Suspicion of purulent pericarditis is an indication for urgent pericardiocentesis, which is diagnostic. The fluid may be frankly purulent. Do fluid biochem and cultures, including blood.
62
ESC. Bacterial --> purulent pericarditis. Treatment?
Management – aggressive.
Recommended: do urgent pericardiocentesis, send fluid and blood for cultures. Effective pericardial drainage is recommended for purulent pericarditis (CRUCIAL).
Administration of intravenous antibiotics (EMPIRIC) is indicated to treat purulent pericarditis.
63
UW. Uremic pericarditis. in what BUN levels occur?
BUN levels >60 mg/dL
64
UW. Uremic pericarditis. Features?
Same as in other pericarditis:
Pleuritic chest pain, pericardial friction rub
65
UW. Uremic pericarditis. treatment?
Dialysis (ecs says it needs to be ,,considered".
66
UW. Uremic pericarditis. What need to rule out prior dialysis?
As >50% of cases are accompanied by pericardial effusion, cardiac tamponade should be ruled out prior to dialysis initiation.
67
ESC. Uremic pericarditis. 3 types may manifest?
uraemic pericarditis—before renal replacement therapy or within 8 weeks of its initiation;
dialysis pericarditis—after being stabilized on dialysis (usually ≥8 weeks after its initiation)
very rarely constrictive pericarditis.
68
UW. Uremic pericarditis. why no ECG?
the absence of ECG abnormalities in most cases, due to the lack of myocardial inflammation
69
ESC. Uremic pericarditis. TYPICAL FEATURES!!!!
lower rate of pleuritic chest pain (up to 30% of patients are asymptomatic) and the absence of ECG abnormalities in most cases, probably due to the lack of myocardial inflammation
70
UW. Uremic pericarditis. why effusion?
Patients with ESRD are more likely to develop chronic pericardial effusion due to continuous volume overload.
71
UW. Uremic pericarditis. what are effusions?
Since pericardial effusion is often bloody in uraemic patients, anticoagulation should be carefully considered or avoided in patients starting dialysis.
72
what is the probable cause?
The most probable cause of uraemic pericarditis is the retention of toxic metabolites.
73
ESC. Uremic pericarditis. dialysis management algo?
consider dialysis. If post dialysis manifests pericarditis, consider to intensify dialysis. If patient does not respond to this treatment, consider pericardial aspiration and/or drainage.
74
ESC. Uremic pericarditis. medications?
NSAIDs and corticosteroids (systemic or intrapericardial) may be considered when intensive dialysis is ineffective. Colchicine is contraindicated in patients with pericarditis and severe renal impairment.
75
ESC. Neoplastic. what most common malignancies?
The most common secondary malignant tumours are lung cancer, breast cancer, malignant melanoma, lymphomas and leukemias.
76
ESC. Neoplastic. confirmation?
The diagnosis is based on confirmation of the malignant infiltration within the pericardium. (fluid + biopsies)
77
ESC. Neoplastic. despite that, what is the most common reason of effusions in these patients?
In almost two-thirds of patients with documented malignancy, pericardial effusion is caused by non-malignant diseases, e. g. radiation pericarditis, other therapies or opportunistic infections.
78
ESC. Neoplastic. Chest X-ray, CT, PET and Cardio MRI may reveal mediastinal widening, hilar masses and pleural effusion. Analyses of pericardial fluid and pericardial or epicardial biopsies are essential for the confirmation of malignant pericardial disease.
Tumor markers - consider
.
79
ESC. Neoplastic. Tamponade, what to do?
Pericardiocentesis
80
ESC. Neoplastic. No Tamponade?
systemic antineoplastic treatment as baseline therapy, (ii) pericardiocentesis to relieve symptoms and establish a diagnosis and (iii) intrapericardial instillation of cytostatic/sclerosing agents to prevent recurrences.
81
ESC. Neoplastic. no tamponade. why drainage is recommended?
Pericardial drainage is recommended in all patients with large effusions because of the high recurrence rate (40–70%).
82
ESC. Radiation pericarditis. Most common malignancies?
Most cases are secondary to radiation therapy for Hodgkin’s lymphoma or breast or lung cancer.
83
ESC. Systemic autoimmune. symptoms?
symptomatic (pericarditis or effusions) or asymptomatic (usually effusion)
84
ESC. Systemic autoimmune. what diseases?
SLE, Sjogren’s syndrome, RA, and scleroderma, but may also be present in systemic vasculitides, Behcet’s syndrome, sarcoidosis and inflammatory bowel diseases.
85
ESC. Systemic autoimmune. treatment?
Targeted etiological search is warranted in cooperation with specialist consultation.
The treatment is especially targeted at control of the systemic underlying disease.
86
ESC. Post MI. Early. diagnostic?
does not differ from acute pericarditis.
87
ESC. Post MI. Early. ECG changes
usually overshadowed by changes due to the myocardial infarction.
88
ESC. Post MI. Early. DO CARDIO ECHO
.
89
ESC. Post MI. Early. treatment?
The treatment is generally supportive, as most cases are self-limited. If this not enough, consider (UW says GIVE) aspirin plus colchicine.
No NSAIDS - can cause wall rupture.
90
ESC. Post MI. Late. Diagnostis - same as early
.
91
ESC. Postoperative effusions. when diasappear?
Postoperative pericardial effusions are relatively common after cardiac surgery.
They usually disappear in 7–10 days, but sometimes they persist for longer and can be dangerous.
92
ESC. Postoperative effusions. Small - good prognosis. moderate/severe --> can lead to tamponade (10 proc.)
.
93
ESC. Postoperative effusions.
In contrast, cardiac tamponade occurring in the first hours after cardiac surgery is usually due to haemorrhage in the pericardial space, and surgical reintervention is mandatory in this situation.
94
UW. Purulent effusions.
spread?
Hematogenous or direct intrathoracic spread
95
UW. Purulent effusions.
Risk factors?
Risk factors: immunosuppression, hemodialysis, recent thoracic surgery/trauma
96
UW. Purulent effusions. m/os?
M/os: Staph. Aureus (most common), Strep. Pneumoniae, Salmonella, Candida
97
UW. Purulent effusions. Clinical features
Acute presentation, patients often appear SEVERELY ILL.
Fevers, chills, chest pain (pleuritic or non-pleuritic)
Can be rapidly fatal
98
UW. Purulent effusions.
Diagnosis 4
ECG: Tachycardia, diffuse ST elevation +/- low voltage QRS
CXR: enlarged cardiac silhouette and clear lung field.
CardioEcho: pericardial effusion
Cytology: turbid fluid with inc. WBC (neutrophil predominant), inc. proteins, decr. Glucose
99
UW. Purulent effusions.
Diagnosis. Whats seen ECG?
Tachycardia, diffuse ST elevation +/- low voltage QRS
100
UW. Purulent effusions.
Diagnosis. Whats seen CXR?
enlarged cardiac silhouette and clear lung field.
101
UW. Purulent effusions.
Diagnosis. Whats seen cardio echo?
pericardial effusion
102
UW. Purulent effusions.
Diagnosis. Whats seen cytology?
turbid fluid with inc. WBC (neutrophil predominant), inc. proteins, decr. Glucose
103
UW. Purulent effusions. treatment? 2
Intravenous ab + pericardial drainage
104
UW. Pericardial effusions in general. most often cause?
Pericardial effusions are often secondary to viral pericarditis (nebūtinai, bet taip sako UW)
105
UW. Pericardial effusions in general. chest ro? 2
Chest X-ray reveals enlarged cardiac silhouette (“water bottle” shaped heart) with clear lung fields
106
UW. Pericardial effusions in general. presentation? 3
a. Beck’s triad
i. Hypotension
ii. incr. JVP (8cm H2O)
iii. Muffled heart sounds
107
UW. Pericardial effusions in general. maximal apical pulse?
5. Point of maximal apical impulse cannot be palpated in patients with large pericardial effusion
108
UW. Pericardial effusions in general. diagnosis? 2
a. EKG: Electrical alternans (QRS complexes whose amplitudes vary from beat to beat)
b. Echocardiography
109
UW. Pericardial effusions in general. Whats seen on ecg?
EKG: Electrical alternans (QRS complexes whose amplitudes vary from beat to beat)
110
UW. Causes of pleuritic chest pain? 4
1. Costochondritis 2. Pericarditis 3. Malignancy 4. Infection (eg, pneumonia
111
UW. costochondritis. what is it?
It is a musculoskeletal chest pain with >= 1 anterior chondral joint (costochondral or sternochondral joints) tenderness
2. It is often caused by joint aggravation during physical activity
3. Presentation: Localized pain of anterior chest -> Worsens with movement, deep inspiration, or coughing
4. Physical examination: a. Tenderness to palpation b. No swelling
5. Management: Reassurance along with topical or systemic analgesics
112
UW. costochondritis. causes?
often caused by joint aggravation during physical activity
113
UW. costochondritis. presentation and physical examination?
Localized pain of anterior chest -> Worsens with movement, deep inspiration, or coughing
Physical examination: a. Tenderness to palpation b. No swelling
114
UW. costochondritis. treatment?
Reassurance along with topical or systemic analgesics
115
UW. pulsus paradoxus. what cases?
a. Cardiac tamponade (most common)
b. Severe asthma
c. COPD
d. Hypovolemic shock
e. Constrictive pericarditis
116
UW. What is pulsus paradoxus?
It is the exaggerated drop in systolic blood pressure (>=10 mm Hg) during inspiration
117
UW. pulsus paradoxus.
3. Note: if the patient has aortic regurgitation, LVEDV increases so much that even in the case of pericardial effusion or cardiac tamponade, pulsus paradoxus does not occur as the increased LVEDV prevents the septal deviation into the left ventricle
.
118
UW. CARDIAC COMPLICATIONS OF HODGKIN LYMPHOMA
1. Acute or delayed pericardial disease
....
3. Restrictive cardiomyopathy
4. Congestive heart failure
5. Valvular abnormalities
6. Conduction defects
2. Myocardial infarction
119
UW. CARDIAC COMPLICATIONS OF HODGKIN LYMPHOMA
.....
2. Myocardial infarction
3. Restrictive cardiomyopathy
4. Congestive heart failure
5. Valvular abnormalities
6. Conduction defects
1. Acute or delayed pericardial disease
120
UW. CARDIAC COMPLICATIONS OF HODGKIN LYMPHOMA
1. Acute or delayed pericardial disease
2. Myocardial infarction
...
4. Congestive heart failure
5. Valvular abnormalities
6. Conduction defects
3. Restrictive cardiomyopathy
121
UW. CARDIAC COMPLICATIONS OF HODGKIN LYMPHOMA
1. Acute or delayed pericardial disease
2. Myocardial infarction
3. Restrictive cardiomyopathy
.....
5. Valvular abnormalities
6. Conduction defects
4. Congestive heart failure
122
UW. CARDIAC COMPLICATIONS OF HODGKIN LYMPHOMA
1. Acute or delayed pericardial disease
2. Myocardial infarction
3. Restrictive cardiomyopathy
4. Congestive heart failure
....
6. Conduction defects
5. Valvular abnormalities
123
UW. CARDIAC COMPLICATIONS OF HODGKIN LYMPHOMA
1. Acute or delayed pericardial disease
2. Myocardial infarction
3. Restrictive cardiomyopathy
4. Congestive heart failure
5. Valvular abnormalities
.....
6. Conduction defects
