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Cardio > Pericarditis > Flashcards

Pericarditis Flashcards

1
Q

What is pericarditis?

A

Inflammation of the pericardium.

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2
Q

What are the two types of pericarditis?

A
  • Acute

- Constrictive

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3
Q

Which type of pericarditis do cardiac tamponade and pericardial effusion usually accompany?

A
  • Acute pericarditis
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4
Q

What is the most common cause of acute pericarditis?

A
  • Viral causes:
  • Enteroviruses e.g. coxsackieviruses & echoviruses
    Adenoviruses
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5
Q

What are some non-infectious causes of acute pericarditis?

A

Autoimmune (next commonest cause):
- Sjorgrens syndrome
- Rheumatoid arthritis
- SLE
Neoplastic; secondary metastatic tumours (common, above all is lung or breast cancer)
Dressler’s syndrome - post cardiac injury syndromes

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6
Q

Briefly describe the pathophysiology of acute pericarditis?

A
  • The Pericardium becomes acutely inflamed, with pericardial vascularisation and infiltration with polymorphonuclear leukocytes
  • A fibrinous reaction frequently results in exudate and adhesions within the pericardial sac, and a serous or hemorrhagic effusion may develop
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7
Q

What are the signs of acute pericarditis?

A
  • Pericardial friction rub present on auscultation
  • Tachycardia
  • Tachypnea
  • Fever and lymphocytosis (increase in lymphocytes) if due to virus or bacteria
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8
Q

You would make a diagnosis of acute pericarditis if 2 of what 4 signs are present?

A
  • Chest pain
  • Friction rub
  • ECG changes
  • Pericardial effusion
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9
Q

What investigation is diagnostic in acute pericarditis?

A

ECG

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10
Q

What would you see on the ECG in pericarditis?

A
  • Widespread concave-upwards - Saddle shaped ST Elevation
  • Diffuse ST segment elevation - present in all leads (must exclude STEMI which would have ST segment elevation but will be limited to the infarcted area e.g. anterior or inferior)
  • PR depression
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11
Q

On the ECG how would you differentiate pericarditis and a STEMI?

A

In pericarditis the ST elevation is in all leads whereas in a STEMI the ST elevation is limited to the infarcted area.

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12
Q

Apart from ECG differences how else would you be able to differentiate between a STEMI and pericarditis?

A

Pain in STEMI will radiate to the neck and jaw and will not be relieved when sitting forward.

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13
Q

What would a CXR show in pericarditis?

A
  • May demonstrate cardiomegaly in cases of effusion - if found then confirm with echocardiography
  • Often normal in idiopathic
  • Pneumonia is common with bacterial pericarditis
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14
Q

If the ESR is raised in pericarditis what is the most likely cause of the inflammation?

A

An autoimmune disease

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15
Q

What is the main management in pericarditis?

A
  • Analgesia for the pain

- Colchicine for 3 months to reduce risk of recurrence - however is limited by nausea and diarrhoea

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16
Q

What is constrictive pericarditis?

A

When certain causes of pericarditis like TB, bacterial infection and rheumatic heart disease result in the pericardium becoming thick and fibrous and calcified.

17
Q

When does constrictive pericarditis become symptomatic?

A

If the pericardium becomes so inelastic that it disrupts the diastolic filling of the ventricles and the cardiac output is therefore decreased.

18
Q

What is constrictive pericarditis very similar to in terms of its presentation?

A

Restrictive cardiomyopathy, here the prognosis is poor and patients usually die less than a year after diagnosis. Constrictive pericarditis however is treatable.

19
Q

What can happen in the later stages of constrictive pericarditis?

A

The sub-endocardial layers of myocardium may undergo fibrosis, atrophy and calcification

20
Q

How does constrictive pericarditis present?

A
  • Kussmaul’s sign - rise in jugular venous pressure and increased neck vein distension during inspiration
  • Pulsus paradoxus - systolic bp drops by >10mmHg during inspiration
  • Diffuse heart sounds
  • Hepatosplenomegaly
  • Ascites
  • Oedema
  • Right heart failure signs
  • Atrial dilatation
21
Q

What investigations would you do in constrictive pericarditis and what are you likely to see?

A
  • CXR: Small heart with or without pericardial calcification
  • ECG: Low-voltage QRS
  • Echocardiography: Thickened, calcified pericardium and small ventricular cavities with normal wall thickness
  • CT/MRI: Helps distinguish it from Restrictive Cardiomyopathy
22
Q

What is the management of constrictive pericarditis?

A

Surgical removal of the pericardium - very risky.

23
Q

What is pericardial effusion?

A

The accumulation of fluid in the pericardial sac. It commonly accompanies an episode of acute pericarditis

24
Q

What is cardiac tamponade?

A

A pericardial effusion that raises intrapericardial pressure reducing ventricular filling thus dropping cardiac output

25
Q

What are the signs of pericardial effusion?

A
  • Soft & distant heart sounds
  • Apex beat obscured
  • Raised jugular venous pressure
  • Bronchial breathing at left base - Ewart’s sign - compressed left lower lobe
26
Q

What are the symptoms of pericardial effusion?

A
  • Dyspnea
  • Chest pain
  • Nausea
27
Q

What are the signs of cardiac tamponade?

A
  • High pulse but low blood pressure
  • High jugular venous pressure
  • Muffled 1st & 2nd heart sounds
  • Kussmaul’s sign - rise in jugular venous pressure and increased neck vein distension during inspiration
  • Pulsus paradoxus - an exaggeration in the normal variation in pulse pressure seen with inspiration, such that there is a drop in systolic blood pressure
  • Reduced cardiac output
28
Q

What would you see on the CXR and on the ECG and on the echocardiogram in both pericardial effusion and cardiac tamponade?

A
  • Large globular heart on CXR
  • Low voltage ORS complexes on ECG
  • Echo-free zone surrounding heart on Echo
29
Q

What are the diagnostic features of cardiac tamponade on an echocariogram?

A
  • Late diastolic collapse of Right Atrium (remember most of L atrium is outside pericardium)
  • Early diastolic collapse of right ventricle
30
Q

What is Becks triad in the diagnosis of cardiac tamponade?

A
  1. Falling blood pressure
  2. Rising jugular venous pressure
  3. Muffled heart sounds
31
Q

What is the treatment of pleural effusion?

A
  • Most pericardial effusions resolve spontaneously
  • Pericardial effusions may re-accumulate most often due to malignancy - this may require a pericardial fenestration (a window in the pericardium is created to allow the slow release of fluid into the surrounding tissues)
32
Q

What is the treatment of cardiac tamponade?

A
  • Seek expert help!
  • Requires Urgent Drainage via a Pericardiocentesis which will drain the fluid to relieve the pressure on the heart
  • Send fluid for culture, Ziehl-Nielsen stain and for cytology

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