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pericarditis Flashcards

1
Q

pericardium

A

Two layers
Visceral (overlying epicardium)
Parietal (Dense fibrous outer layer)
Pericardial sac holds about 15-50ml

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2
Q

pericarditis

A

Inflamation of pericardium
May contain exudates, adhesions, blood, or serous type fluid.
Often not apparent clinically
Mortality in untreated purulent pericarditis is nearly 100% (but not majority of cases)

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3
Q

fibrinous pericarditis

A

Caused by:
-Dressler’s syndrome:
Delayed pericarditis 2-10 wks after mi due to antibodies.
Responds well to corticosteroids
-Uremia
-Radiation
Loud friction rub, “bread and butter” appearance

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4
Q

serous pericarditis

A

Noninfectious inflammatory disease:
Rheumatic fever
SLE
Viral infections (often coxsackie)

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5
Q

suppurative/purulent pericarditis

A

Caused by bacterial, fungal and parasitic infectious agents

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6
Q

pericarditis etiology

A

viral or idiopathic (most common) mortality is practically nonexistent. (There is also no distinguishing clinical features between these two; idiopathic, presumed viral)

More common in men
More common in adults

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7
Q

peri Most common symptom

A

Chest pain: SubsternalSharp, stabbing, burning, pressing
SOB–especially if pericardial effusion
May radiate to back, neck, shoulder, arm

*Pain referral to LEFT trapezius ridge quite specific!! Why do you think this is?? Inflammation of the joining diaphragmatic pleura!!!

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8
Q

key symptom in hx

A

(pleuritic) Chest pain worse when supine, with inspiration, swallowing (dysphagia) and with body motion
-Chest pain better sitting up, leaning forward
-This helps sometimes to distinguish angina from pericarditis…in that angina does not change with position
H/P paramount in diagnosis

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9
Q

Other symptoms and findings

A

Fever; usually low grade
Pericardial friction rub (almost pathognomonic)
Dyspnea; chest pain worse with inspiration (pleuritic: ddx: PE)
Dysphagia; irritation of esophagus
Tachypnea
Tachycardia
Beck’s triad

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10
Q

Beck’s triad test question

A

Hypotension, JVD, muffled heart sounds

cardiac tamponade

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11
Q

pericarditis causes

A 
Idiopathic--accounts for most cases—assumed viral
Malignancy
Drug induced
Radiation therapy induced
Uremia/renal failure
Acute STEMI
*Post MI (dressler syndrome)*
Auto-immune, rheumatic (SLE, RA, scleroderma, sacrcoidosis)
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12
Q

Drug induced pericarditis

A

Procainamide, hydralazine, isoniazid (INH)

seizure think INH OD

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13
Q

Bacterial causes

A 
*staphylococcus most common* (on test)
Streptococcus
pneumococcus
Neisseria
Legionella
Lyme disease

Via direct pulmonary extension, endocarditis, penetrating injury, hematogenous spread

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14
Q

viral causes

A

most common assumed cause
Coxsackie
Echovirus
HIV
Herpes
varicella
Measles, mumps
EBV
hepatitis, RSV

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15
Q

more causes

A

Fungal:
Histoplasmosis
Coccidiomycosis

TB
Hypothyroidism
cholesterol

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16
Q

Pericardial friction rub

A

Most common and important physical finding
Best with diaphragm of stethoscope,Lower left sternal border or apex
Sitting, leaning forward
Intermittent
Grating or scratching sound–leather rubbing against leather
Three components

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17
Q

EKG dx

A 
Serial ekgs over a period of days/weeks
Four stages (KNOW)
18
Q

EKG stage 1

A
  • ST segment elevation*/acute phase
  • Subepicardial injury/inflamation
  • Diffuse* ST elevation (multiple leads, not just 1 anatomical area) smiley face, notch
  • PR depression*
19
Q

EKG stage 2

A

ST segments start returning to normal
T-wave amplitude decreases in height
(may still have PR depression)

20
Q

EKG stage 3

A

T-wave inversions appear

Normal ST segments now present

21
Q

EKG stage 4

A

normalization

22
Q

ST elevation may be ??

A

benign, esp. in young ppl

early repolarization

STEMIs don’t usually have concavity (smiley face) (more convex)

also small notch before elevation in early repol, not STEMI

23
Q

complication: pericardial effusion (does not have to be due to pericarditis, and not all pericarditis pts have pericardial effusion)

A

Collection of fluid in the pericardial sac
-Can be so great as to hamper cardiac function (e.g., cardiac tamponade)…death
-Acute symptoms with 80ml of fluid–>symptomatic
Chronic build up with collections of 1-2 liters of fluid in sac (pop bottle!)
-EKG classically described by low voltage (short amplitude QRS-has to transfuse thru fluid) and electrical alternans; caused by pendular motion of beating heart in a large fluid filled sac.

24
Q

electrical alternans

A
  • alternating QRS amplitude/axis
  • low voltage QRS (also for obese pts)
  • specific to pericardial effusion
25
Q

pericarditis CXR

A

Limited value
-May be of normal size–even in setting of pericardial effusion or tamponade
If previous cxr available for comparison, may see an interval enlargement of heart size between the two

26
Q

Pericardial fat pad sign

A

Seen on lateral CXR
Epicardial fat allows the silhouette of two layers of pericardium to appear separate from the heart
-Pericardial effusion; Sometimes pericarditis
Not commonly seen (typ. get AP not lateral view)

27
Q

cardiac ECHO

A

will help immensely

Cardiac echo can easily diagnose a pericardial effusion (test of choice)

Pericarditis is characterized by inflammation of the pericardial layers….this can cause a pericardial effusion
(so will see effusion on ECHO, not pericarditis)

28
Q

CT scan slide 39

A

pericardial effusion, fluid left back of lung: also have pleural effusion (possibly malignant, blood, pus)

29
Q

CXR

A

“water bottle” (jug?) heart (like a flask)

cannot dx on this, pericardial effusion is a clinical dx

30
Q

pericardiocentesis

A

insert needle at 45 degree angle below xiphoid process

put metal EKG lead on needle, will get spike when hit pericardium

31
Q

pericarditis labs

looking for the etiology

A 
CBC: may reveal elevated WBC or leukemia
Chem: may reveal uremia
Streptococcal serologic tests: In pts with hx of rheumatic heard disease or pharyngitis
Blood cultures/viral cultures
UA, UDS
Tb,hiv
ESR (sed rate)
Thyroid tests (TSH)
Rheumatologic studies (ana, rf, etc.)
Cardiac markers (troponin, cpk-mb)
**pericardiocentesis for Cx/Sn if purulent expected
32
Q

do Pericardial biopsy…if no ??

A

improvement for 3 weeks

33
Q

pericarditis tx

A

If idiopathic or presumed viral: NSAIDS 1-3 weeks (motrin)
Identify/treat cause

If bacterial, treat > 4 weeks antibiotics. Also, pericardiocentesis should be performed.

34
Q

poor px indicators

A 
Immunosupression
Myocarditis
Severe pericardial effusion
Fever
Nsaid failure
Trauma
Oral anticoagulation (more blood around heart)
35
Q

Constrictive pericarditis

A

A possible result of pericardial injury, post trauma, post op

  • Fibrous thickening of pericardium, Thickened noncompliant pericardial sac
  • Slowly progressive, Usually specific cause not determined
  • Defined “…when such fibrous response results in a decrease in passive diastolic filling of the normally distensible cardiac chambers…”
36
Q

contrictive pericarditis Most commonly results from: ??

A

Cardiac trauma/intrapericardial bleeding

  • Open heart surgery
  • Idiopathic, Fungal, tb (in developing world), viral (in developed world), uremic
37
Q

Constrictive pericarditis s/s

A

Dyspnea, worsening with exertion!!!
CP, PND, orthopnea, B/L LE edema, JVD

Pericardial knock:
After 2nd heard sound.
Due to accelerated RV inflow, followed by abrupt slowing of ventricular expansion:
Diastole
The RA is pouring into RV, but due to poor RV compliance, there is no RV expansion.

38
Q

cardiac tamponade (boards)

A

Compression of heart by fluid in pericardium—blood, pericardial effusion, etc.
-Leads to decreased CO
-Equilibration of diastolic pressures in all 4 chambers (bad! no reason for ventricles to fill)
*Becks triad (low bp, distended neck veins, distant heart sounds)
tachycardia

39
Q

cardiac tamponade: Pulsus paradoxus:

A 
decreased SBP by 10 mmHg during inspiration--
also seen in:
asthma
obstructive sleep apnea
pericarditis
croup
40
Q

myocarditis FYI

A

Inflammation of heart MUSCLE
May be a secondary to a primary infection, e.g., pericarditis
-Viral: Coxsackie B, adenovirus, echovirus, influenza, EBV, HIV
-Bacterial: corynebacterium diphtheriae, Lyme dz, B-hemolytic strep (rheumatic fever), mycoplasma pneumonia, neisseria meningitidis,
-*1/3 develop to DCM

CSI (75 decks)

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