pericarditis Flashcards
pericardium
Two layers
Visceral (overlying epicardium)
Parietal (Dense fibrous outer layer)
Pericardial sac holds about 15-50ml
pericarditis
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)
fibrinous pericarditis
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
serous pericarditis
Noninfectious inflammatory disease:
Rheumatic fever
SLE
Viral infections (often coxsackie)
suppurative/purulent pericarditis
Caused by bacterial, fungal and parasitic infectious agents
pericarditis etiology
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
peri Most common symptom
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!!!
key symptom in hx
(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
Other symptoms and findings
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
Beck’s triad test question
Hypotension, JVD, muffled heart sounds
cardiac tamponade
pericarditis causes
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)
Drug induced pericarditis
Procainamide, hydralazine, isoniazid (INH)
seizure think INH OD
Bacterial causes
*staphylococcus most common* (on test) Streptococcus pneumococcus Neisseria Legionella Lyme disease
Via direct pulmonary extension, endocarditis, penetrating injury, hematogenous spread
viral causes
most common assumed cause
Coxsackie
Echovirus
HIV
Herpes
varicella
Measles, mumps
EBV
hepatitis, RSV
more causes
Fungal:
Histoplasmosis
Coccidiomycosis
TB
Hypothyroidism
cholesterol
Pericardial friction rub
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
EKG dx
Serial ekgs over a period of days/weeks Four stages (KNOW)
EKG stage 1
- ST segment elevation*/acute phase
- Subepicardial injury/inflamation
- Diffuse* ST elevation (multiple leads, not just 1 anatomical area) smiley face, notch
- PR depression*
EKG stage 2
ST segments start returning to normal
T-wave amplitude decreases in height
(may still have PR depression)
EKG stage 3
T-wave inversions appear
Normal ST segments now present
EKG stage 4
normalization
ST elevation may be ??
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
complication: pericardial effusion (does not have to be due to pericarditis, and not all pericarditis pts have pericardial effusion)
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.
electrical alternans
- alternating QRS amplitude/axis
- low voltage QRS (also for obese pts)
- specific to pericardial effusion
pericarditis CXR
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
Pericardial fat pad sign
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)
cardiac ECHO
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)
CT scan slide 39
pericardial effusion, fluid left back of lung: also have pleural effusion (possibly malignant, blood, pus)
CXR
“water bottle” (jug?) heart (like a flask)
cannot dx on this, pericardial effusion is a clinical dx
pericardiocentesis
insert needle at 45 degree angle below xiphoid process
put metal EKG lead on needle, will get spike when hit pericardium
pericarditis labs
looking for the etiology
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
do Pericardial biopsy…if no ??
improvement for 3 weeks
pericarditis tx
If idiopathic or presumed viral: NSAIDS 1-3 weeks (motrin)
Identify/treat cause
If bacterial, treat > 4 weeks antibiotics. Also, pericardiocentesis should be performed.
poor px indicators
Immunosupression Myocarditis Severe pericardial effusion Fever Nsaid failure Trauma Oral anticoagulation (more blood around heart)
Constrictive pericarditis
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…”
contrictive pericarditis Most commonly results from: ??
Cardiac trauma/intrapericardial bleeding
- Open heart surgery
- Idiopathic, Fungal, tb (in developing world), viral (in developed world), uremic
Constrictive pericarditis s/s
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.
cardiac tamponade (boards)
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
cardiac tamponade: Pulsus paradoxus:
decreased SBP by 10 mmHg during inspiration-- also seen in: asthma obstructive sleep apnea pericarditis croup
myocarditis FYI
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
