Pericarditis Flashcards
What is the pericardium?
Fibroelastic sac
Visceral and parietal layers with pericardial cavity between them
15-50 mL of plasma ultrafiltrate
Definition of acute pericarditis
Rapidly developing inflammation of the pericardium
What is the most common cause of pericarditis?
idiopathic!
What are some causes of pericarditis?
Radiation Neoplasm Trauma Autoimmune Metabolic ---Hypothyroidism ---Uremia
Cardiac causes of pericarditis
Early infarction pericarditis
Last post cardiac injury (Dresslers)
Myocarditis
Dissecting aortic aneurysm
What drugs can cause pericarditis? How?
Via drug induced lupus
Procainamide
Isoniazid
Hydralazine
Acute pericarditis - important viral, bacterial, and fungal causes
Viral
-coxsackie, echovirus, adenovirus, influenze, HIV
TB/histoplasmosis
Acute pericarditis pathologic anatomy
Usually fluid accumulation - most commonly serous
Bacteria or tumor cells
Sometimes bacterial infection causes a purulent pericarditis
Fluid may resolve or form adhesions
What sort of change is there is the surface of the heart with pericarditis?
It becomes roughened
–sometimes described as bread and butter pattern
Clinical features of pericarditis
Chest pain
Pericardial friction rub
ECG changes
Pericardial effusion
Acute pericarditis Presentation - chief complaints
Chest pain unrelated to exertion
Fatigue, dyspnea, malaise
Fever
(so basically flu like symptoms other than chest pain)
Type of chest pain seen with acute pericarditis
Sudden onset of pleuritic chest pain
- -sharp, stabbing
- -worse on deep inspiration and laying flat, better leaning forward
Pericardial friction rub is due to ..
What does it sound like?
friction between the two inflammated layers of pericardium
Scratchy, leathery sound - higher pitch than diastolic filling sounds
- —best heart with the diaphragm
- —heard over left sternal border
ECG findings with acute pericarditis
These changes signify …
Sinus tachycardia
ST elevation and PR depression
- –aVR opposite
- –ST changes are diffuse and not well correlated to acute ischemia or a single vessel
Changes signify inflammation of the epicardium, since the parietal pericardium itself is electrically inert
Acute pericarditis complications
Pericardial effusion & tamponade
Constrictive pericarditis (late)
Relapse
How do we treat idiopathic and viral causes of pericarditis?
Combination of NSAIDs (2 weeks) and colchicine (3 months)
How do we treat pericardicitis post MI?
Aspirin and colchicine
Avoid NSAIDs since they may interfere with healing and scar formation
When would glucocorticoids by used in pericarditis?
In patients with symptoms refractory to standard therapy
Acute pericarditis due to CT disease
Uremic pericarditis
(use these rarely and cautiously b/c of concern of recurrence of pericarditis)
What is a pericardial effusion?
How does this relate to tamponade?
Accumulation of fluid in pericardial space
Pericardial fluid pushing on the heart creates tamponade
What ECG changes are seen with pericardial effusion (and pericardial tamponade)?
- sinus tach
- low voltages (of all QRS)
- electrical alternans
What is the presentation of pericardial tamponade like?
- Depends on chronicity of the process
- ‘CHF’ symptoms with clear lungs
- Unexplained signs of R heart failure (edema, increased JVP)
- New ‘cardiomegaly’ on CXR
- ECG changes
Pericardial tamponade - pathophysiology
Pericardial fluid increases intrapericardial pressure which impedes diastolic filing of LV and RV
RV and LV diastolic pressure rises SV and CO decrease Systemic BPdrops Pulse pressure narrows HR increases
Pulsus paradoxus
- definition
- what is this seen with?
- what is the mechanism behind this?
Fall of systolic blood pressure > 10 mmHg with inspiration
Seen with tamponade
With compressive fluid, the increase in venous return causes septal shift impinging on LV volume
How do we check for pulsus paradoxus?
Can check by measuring the difference in systolic pressure
BUT, shouldn’t do this, instead
listen for the difference in when you start hearing rare korotkof sounds to when you start hearing all of them regularly
Physical findings of pericardial tamponade
Sinus tach Tachypnea Hypotension (late) with narrow pulse pressure Elevated JVP with loss of Y descent Edema Pulsus paradoxus
Treatment of pericardial tamponade
Medical emergency! IVF (temporizing) Vasopressors as needed Prompt pericardiocentesis Pericardial windown
AVOID diuretics, vasodilators, etc.
What labs should be done on someone with pericarditis?
Cardiac enzymes Inflamation markers (CRP, ESR, WBCs) Thyroid fxn studies Renal fxn studies Body fluid cultures TB skin test
What is constrictive pericarditis?
Chronic thickening/scarring of pericardium leading to encasement of the heart and impaired diastolic filling of LV and RV
Pathophysiology of constrictive pericarditis
Early diastolic filling unimpaired
Chambers expand and collide with unyielding pericardium which halts further diastolic filling
“dip and plateau” or “square root” sign seen on pressure tracing
Constrictive pericarditis clinical presentation
Slow, indolent process
Unexplained right heart failure
- -systemic congestion (edema, ascites, hepatomegaly)
- -fatigue
- -dyspnea
Often misdiagnosed as cirrhosis
Physical findings with constrictive pericarditis
Elevated JVP with prominent X and Y descents
—(notice this is different than with tamponade)
Kussmaul’s sign
Pericardial knock
Systemic congestion
—hepatometgaly, ascites, edema
What is Kussmaul’s sign?
Lack of an inspiratory decline in JVP
What are the differences in patterns in jugular venous pressures in tamponade and constriction?
tamponade - loss of y descent
constriction - prominent x and y descents
When is the pericardial knock heart?
After S2
During diastole
What do we seen on a pressure tracing of all chambers when someone has constrictive pericarditis?
Equalization of diastolic pressures
Chronic pericarditis can lead to what CXR findings?
calcification
Constrictive pericarditis therapy
Diuretics
Pericardial stripping
