Pericarditis Flashcards
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%
Fibrinous Pericarditis
Caused by: Dressler’s syndrome (delayed pericarditis 2-10 wks after mi due to antibodies. Responds well to corticosteroids), Uremia or Radiation
- Hear loud friction rub
- “Bread and butter” appearance
Serous Pericarditis
-From noninfectious inflammatory diseases:
Rheumatic fever, SLE,
Viral infections (often coxsackie)
Suppurative/Purulent Pericarditis
Caused by bacterial, fungal and parasitic infectious agents
Most common form is
idiopathic, presumed to be viral (if they can’t pinpoint what’s causing it)
Symptoms
**Chest pain** Most common symptom Substernal Sharp, stabbing, burning, pressing SOB--especially if pericardial effusion May radiate to back, neck, shoulder, arm **Pain referral to left trapezius ridge** (upper back/top of shoulder)
What is pain from pericarditis referred to left trapezius ridge
Inflammation of the joining diaphragmatic pleura!!!
Key symptoms in history
- Chest pain worse when supine (laying down), with inspiration (pleuritic), swallowing (dysphasia) 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.
Other S/S
-Fever; usually low grade
-Pericardial friction rub
-Dyspnea; chest pain worse with inspiration
-Dysphagia; irritation of esophagus
-Tachypnea
-Tachycardia
Beck’s triad ON TEST
Hypotension, JVD, muffled heart sounds
cardiac tamponade
What is Beck’s Triad
Hypotension, JVD, muffled heart sounds
cardiac tamponade
Drug induced causes
Procainamide, hydralazine, isoniazid (INH)
Other causes
-Malignancy
-Radiation therapy induced
-Uremia/renal failure
-Acute stemi
Post myocardial infarction (dressler syndrome)
-Autoimmune, rheumatic (SLE, RA, scleroderma, sacrcoidosis)
-Fungal (Histoplasmosis,
coccidiomycosis)
-Tuberculosis
-Hypothyroidism
-Cholesterol
Bacterial causes
- *Staphylococcus most common**
- Streptococcus
- pneumococcus
- Neisseria
- Legionella
- Lyme disease
- Via direct pulmonary extension, endocarditis, penetrating injury, hematogenous spread
Viral causes
(VIRAL= most common assumed cause)
- *Coxsackie**
- Echovirus
- HIV
- Herpes
- varicella
- Measles, mumps
- EBV
- hepatitis, RSV
Most common and important finding is
- Pericardial friction rub
- Best with diaphragm of stethascope
- Lower left sternal border or apex
- Sitting, leaning forward
- Intermittent
- Grating or scratching sound–leather rubbing against leather
- Three components
EKG findings for pericarditis (KNOW FOR EXAM!)
-serious of EKGs taken over days/weeks
4 stages observed:
1- ST elevation (Diffuse, seen in almost all leads); PR depression
2- Still have PR depression (ST segment elevation has resolved)
3- T wave inversion (diffuse)
4- Normalization
Pericardial Effusion
- a complication of pericarditis
- Collection of fluid in the pericardial sac
- Can be so great as to alter cardiac function (e.g., cardiac tamponade)…death
- Acute symptoms with 80ml of fluid
- Chronic build up with collections of 1-2 liters of fluid in sac
- EKG classically described by low voltage (amplitude of QRS are short, SHORT QRS, they don’t look tall) and electrical alternans; caused by pendular motion of beating heart in a large fluid filled sac.
Specific EKG findings for pericardial effusion
- Electrical Alternans
- See high amp QRS then low amp QRS (tall, short, tall, short)
- Specific for pericardial effusion!!! NOT specific for pericarditis*
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
Test of choice to diagnose pericardial effusion
- Pericarditis is characterized by inflamation of the pericardial layers….this can cause a pericardial effusion
- can find pericardial effusion as a complication; NOT used to diagnose actual pericarditis
CXR may show
“Water Bottle Heart”
May see large pericardial effusion
-Can’t diagnose cardiac tamponade (need to use clinical s/s for that)
Labs to order
-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 C&S if purulent expected
-Pericardial biopsy (if no improvement for 3 weeks)
Treatment
- If idiopathic or presumed viral use NSAIDs for 1-3 weeks
- Identify/treat cause
- If bacterial, treat > 4 weeks w/ antibiotics
- Pericardiocentesis should be performed
Poor prognostic indicators
- Immunosupression
- Myocarditis
- Severe pericardial effusion
- Fever
- NSAID failure
- Trauma
- Oral anticoagulation
