Pericarditis Flashcards
What can chronic pericardial inflammation lead to
rigid, thickened, calcified pericardium
What are the causes of pericardial disease
Viral Bacterial Fungal Parasitic Systemic inflammatory dz (SLE) Malignancy Uremia
Why is the epidemiology of pericarditis
in 0.1-0.2% of hospitalized patients
up to 5% of ED patients with non-ischemic CP
What is the most common cause of acute pericarditis
Idiopathic
most are undiagnosed VIRAL infections; coxsackie B, Influenza
What is the most common presenting symptom in acute pericarditis
CHEST PAIN; sharp and pleuritic, improves by leaning forward, exacerbated by cough
Describe pericardial CP vs ischemic CP
Pericardial: sudden one, anterior chest, sharp, pleuritic, improves leaning forward, worse with cough inspiration or lying flat
Ischemic: radiates, relieved with nitro
What is common to see on pericarditis PE
Pericardial friction rub; squeaky, scratchy over LSB
What are characteristic ECG findings for pericarditis
Diffuse ST elevation (concave upward) and PR segment depression
Stage 1: diffuse ST elevation and PR depression
Stage 2: normal
Stage 3: diffuse deep T wave inversion
Step 4: normal
What other diagnostic tests should you get
CT (shows thick pericardium)
Cardiac MRI
Echo (normal unless effusion present)
Are pericardiocentesis and pericardial biopsy used in acute pericarditis
Rarely, they are low yield
but can be therapeutic and diagnostic
Pericardiocentesis if refractory to med therapy or in hemodynamic compromise
Biopsy if illness >3 weeks, or recurrent
What lab tests would be elevated in acute pericarditis
Troponin
High CRP, ESR, and WBC can help support the diagnosis
(if patient is febrile check blood cultures)
What further work up should you consider if patient isn’t improving
ANA, rheumatoid factor
TB testing
HIV serology
Malignancy work up
What is the diagnostic criteria for acute pericarditis
Need TWO of the following:
- Typical CP
- Pericardial friction rub
- Characteristic ECG changes
- Pericardial effusion
What is pericarditis admittance criteria
Fever immunocompromised subacute onset Hemodynamic compromise Oral anticoagulants (hemorrhagic effusion) trauma
How do you medically manage acute pericarditis
NSAIDs +/- Colchicine (reduce sx and decrease rate of recurrence) 2 weeks or less
-If pt can’t take NSAIDs, give glucocorticosteroids
-Activity restriction until Sx resolved and biomarkers normalize
How long until a patient shows improvement with medical management of pericarditis
within one week
if Sx persist, may need more workup
What is a pericardial effusion
amount of fluid in pericardium more than normal (15-50 ml) secondary to injury to pericardium
acute, subacute, or chronic
What kind of effusion progression is better
Slower development; the pericardium has more time to stretch and adapt
How does a pericardial effusion usually present
Asymptomatic!
May have CP/pressure/discomfort relieved by sitting up or leaning forward
Syncope, light headed, palpitations, Resp. Sx
What can you find on pericardial effusion PE
Usually none unless hemodynamically significant
**Pulsus Paradoxus (SBD decrease >10 with inspiration) = falling CO during inspiration
How do you measure Pulsus Paradoxus
When taking BP, listen for first korotkoff sound only on expiration, deflate cuff until you hear during inspiration and expiration
If difference >10, positive test
What is characteristic of an ECG for pericardial effusion
Low voltage QRS
- Sinus tachy
- *Electrical alternans (normal then abn QRS)
- **= highly specific for pericardial effusion
What is a characteristic CXR finding for pericardial effusion
Enlarged cardiac silhouette
What is your imaging modality of choice for pericardial effusion
ECHOCARDIOGRAM (large effusion= >20 mm)
What diagnostic exam is low yield for pericardial effusion
Pericardiocentesis
Indicated if impending hemodynamic compromise, suspected infectious, or uncertain etiology
How do you treat pericardial effusion
NSAID +/- Colchicine if with pericarditis
treat underlying cause
refractory cases need recurrent pericardiocentesis
What is a chronic pericardial effusion
Present for >3 months, asymptomatic, hemodynamically tolerated
Pericardectomy needed if fluid reaccumulates despite repeat pericardiocentesis
What is a hemorrhagic pericardial effusion
When blood fills the pericardial space, most likely due to malignancy (can also be Iatrogenic, MI complication like free wall rupture)
What is cardiac tamponade
compression of heart chambers due to increased pericardial pressure (pericardium has reached max capacity)
How does blood flow in the heart change with cardiac tamponade
Diastolic compliance reduced (less room)
RV bows into LV during inspiration and decreases filling more causing decrease in CO and BP
What are the causes of cardiac tamponade
Acute within minutes, due to trauma , leads to cariogenic shock
Subacute occurs days-weeks, neoplastic
Regional occurs s/p MI or post-pericardectomy, and only select chambers are compressed
What are symptoms of cardiac tamponade
DYSPNEA
fatigue, chest discomfort, peripheral edema
What is Becks Triad (seen with cardiac tamponade)
- Hypotension
- JVD
- Muffled heart sounds
How do you know if your patient is in cariogenic shock
On exam, cold clammy extremities with mottled skin
Indicate poor end organ perfusion due to cardiac dysfunction
While diagnosis is CLINICAL, what can help you diagnose cardiac tamponade
ECG: Electrical alternates and Low voltage QRS
Echo: hemodynamic significance
Labs: + based on underlying cause (from fluid sample)
How do you treat cardiac tamponade
CARDIO CONSULT
**Urgent Echo guided pericardiocentesis OR
Surgical drainage
What is constrictive pericarditis
CHRONIC Scarring of normal elasticity of pericardial sac making it rigid and thick
Cause reduced CO and SV
Why does systemic venous return increase on inspiration with cardiac tamponade but NOT with constrictive pericarditis
In tamponade, pericardial space is open (fluid filled) but in CP, it is all thick so filling won’t change with respiration
What causes constrictive pericarditis
Any pericardial disease process
idiopathic or viral
S/p radiation or cardiac surgery or infection
How does CP usually present
*Symptoms of RHF (peripheral edema, anasarca)
fatigue, dyspnea, DOE (reduced CO)
What will you see on CP physical exam
Elevated JVP
Kussmaul’s sign
Pericardial Kock (before S3)
What are charac. CP diagnostic exam findings (ECG, CXR, Echo, MRI)
ECG: non-specific ST/T wave changes
CXR: pericardial CALCIFICATION
Echo: abnormal passive filling
MRI: tells you effusion vs thickening
What is the treatment for CP
Conservative treatment for 2-3 months
If persistent, pericardectomy**
(diuretics can temp reduce Na)
How can you tell the difference between CP and RCM
Both have high filling pressure and normal systole, and Kussmaul’s sign
CP: pt has had prior pericarditis or systemic disease. Pericardial knock!
RCM: pt has amyloidosis
