Pericarditis Flashcards
Layers of the normal pericardium
Outer fibrous layer – no vital function
Inner serous layer – lubricates, anchors the heart. Has two layers – visceral and parietal.
Cause of acute pericarditis
Viral: Coxsackie, Echovirus
TB
Bacterial
Non infectious: Post MI Severe hypothyroidism Cardiac surgery Trauma Mediastinal radiation Drugs and Toxins SLE, RA
If pericarditis is caused by an MI, how big is the lesion?
It’s related to infarct size.
Early post-MI pericarditis vs late post-MI pericarditis
Inflammatory, but weeks to months later mostly immune mediated process.
Post cardiac injury syndrome
Months to weeks after MI, immune mediated pericarditis
Symptoms of acute pericarditis
Retrosternal chest pain due to friction. Related to position.
Rare fever, dyspnea
Signs of pericarditis on exam?
Peristernal friction rub – highly specific. Best heard when patient is sitting and expiring.
EKG findings of acute pericarditis?
Don’t worry about it now. But know that there’s universal ST elevation.
How to treat acute pericarditis
Aspirin
Colchicine
Steroids if recurrent
Complications of acute pericarditis
Constriction from scarring and loss of elasticity.
Cardiac tamponade, accumulation of pericardial fluid under pressure.
Recurrent pericarditis
Etiology of pericardial effusion
Viral, bacterial, tb
Malignancy, uremia, radiation, trauma, dissecting aneurysm
Symptoms of pericardial effusion
Sometimes asymptomatic
Dyspnea, cough, hoarseness, abdominal fullness
Signs of pericardial effusion on exam
Muffled heart sounds, Ewart’s sign.
Ewart’s Sign
Dullness to percussion of subscapular area. Sign of pericardial effusion
How does pericardial effusion appear on x-ray?
Flask like appearance of heart – water bottle.
How to treat effusions?
Drain them with a needle, unless it’s an aortic dissection
Cardiac tamponade
Hypotension, tachycardia
Occurs when intrapericardial pressure exceeds intracardiac pressure. Ventricles cannot contract and low SV.
What is development of tamponade based upon?
Time of development, not amount of fluid.
Effect of breathing on heart in tamponade
During inspiration, large volume of blood floods right side. Because heart can’t expand out, the septum will push and expand to the left side of the heart, which diminishes filling. Decreased SV.
During expiration, the septum will push on the right side of the heart.
Pathophysiology of cardiac tamponade and constrictive pericarditis
Impaired diastolic filling of ventricles leads to elevated venous pressures (causing pulmonary congestion and systemic congestion), and impaired stroke volume– decreases CO.
Symptoms of cardiac tamponade
Dyspnea, orthopnea, fatigue
Beck’s Triad
Decreased arterial pressure, increased venous pressure, distant heart sounds
Other signs of cardiac tamponade that aren’t decreased arterial pressure, increased venous pressure and decreased heart sounds.
Tachycardia Pulsus paradoxus Increased JVP Decreased systolic blood pressure with narrow pulse pressure Muffled heart sounds Ewart's Sign
Pressure tracing of RA or JVP with tamponade or constriction
Tamponade: Very shallow Y descent because right ventricle is compressed.
Constriction: Deep Y descent because higher atrial pressures without ventricles being too constricted.
Pulsus paradoxus
Exaggerated drop in systemic blood pressure with inspiration because RV expands into LV and impairs filling so SV decreases.
Septum must be intact to occur
How to treat tamponade
Pericardiocentesis along with IV fluids and pressor agents
Constrictive pericarditis effect on heart
Impedes diastolic filling of the heart. No effect on systolic function.
What happens in constrictive pericarditis
Diastolic heart failure – exertional dyspnea, R>L CHF, peripheral edema
Causes of constrictive pericarditis
Heart surgery, radiation, connective tissue diseases (RA, SLE), infection, malignancy
Kussmaul’s sign
Distention in jugular veins with inspiration. This is paradoxical. Seen when ventricles resist filling. Seen in tamponade more than constriction because of the lack of a y descent.
How to treat constrictive pericarditis?
Remove it
Pericardial Knock
When ventricle fills during diastole (S3). Increase.
