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CARDIOVASCULAR MEDICINE > PERICARDITIS AND PERICARDIAL EFFUSIONS > Flashcards

PERICARDITIS AND PERICARDIAL EFFUSIONS Flashcards

1
Q

What is the normal volume of fluid held within the healthy pericardium?

A

50 mL

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2
Q

What are the causes of acute pericarditis?

A

Infection
Acute MI
Uraemia
Autoimmune disease (SLE, rheumatic fever, RA, scleroderma)
Neoplastic disease
Other inflammatory disease (sarcoidosis, Whipple’s disease, Behcet’s syndrome)

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3
Q

What are the viruses commonly associated with acute viral pericarditis?

A

Coxsackie virus A and B
Echovirus
EBV
HIV

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4
Q

What are the bacteria commonly associated with acute bacterial pericarditis?

A

Pneumococci, staphylococcus, Gram-negative organims, Neisseria meningitidis, N. gonorrhoeae, Tuberculosis

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5
Q

What are the symptoms associated with acute pericarditis?

A

Sharp chest pain (central or left sided)
Pain alleviated sitting forwards
Aggravated by lying down or coughing
Dyspnoea - pain of deep inspiration

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6
Q

On examination, what signs might you find in a patient with acute pericarditis?

A

Fever
Tachycardia
Pericardial friction rub on ausculatation
Reduced heart sounds

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7
Q

Can you describe a pericardial friction rub?

A

High pitched scratching sound
Varies with time and may disappear
Sounds closer to the ear than a murmur

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8
Q

What investigations would you order for someone with suspected acute pericarditis?

A 
Standard blood tests 
Autoantibody titres
Cardiac enzyme and markers (troponin)
Blood cultures
ECG
Chest x-ray
Echo
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9
Q

What might blood tests show in someone with acute pericarditis?

A 
Inflammatory picture
Raised WCC
Raised ESR
Raised CRP
Antinuclear autoantibodies
Rheumatoid factor
Cardiac enzymes
Troponin T/I
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10
Q

If troponin T or I is elevated in a patient with acute pericarditis, what does this suggest?

A

That the inflammatory process involves the myocardium (myopericarditis)

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11
Q

What might the ECG of someone with acute pericarditis show?

A

Concave (saddle-shaped) ST elevation in all leads except AVR and V1
T-wave flattening or inversion a few days later

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12
Q

What might a chest x-ray of someone with acute pericarditis show?

A

Nothing in most uncomplicated cases
Pericardial effusion may be seen as enlargement of cardiac shadow
Pleural effusion

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13
Q

What is the best method of investigation to confirm a pericardial effusion?

A

Echo

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14
Q

What is the management of someone with uncomplicated viral or idiopathic acute pericarditis?

A

Bed rest and analegesia (NSAIDs)

Occasionally oral corticosteroids

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15
Q

What is the life threatening complication of acute pericarditis?

A

Cardiac tamponade

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16
Q

How is cardiac tamponade treated?

A

Oxygen
Bed rest - increase venous return
Pericardiocentesis - Drained with wide bore cannula inserted at the xiphisternum and directed towards the left shoulder under ECG monitoring. Once you see ECG changes, pull back slightly and leave to drain. Fluid should be sent for microscopy, culture and biochemical analysis of protein content.

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17
Q

What is Dressler’s syndrome?

A

Type III autoimmune reaction leading to a syndrome of fever, pericarditis and pleurisy occuring more than 1 week after a cardiac operation or myocardial infarction. Antibodies form against pericardial antigens.

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18
Q

How do patients with Dressler’s syndrome present?

A 
Fever
Malaise
Chest pain
Classic signs of pericarditis
Arthritis
19
Q

How is Dressler’s syndrome managed?

A

NSAIDs
Aspirin
Corticosteroids

20
Q

What sign might you see on the skin of a patient with pericarditis caused by uraemia?

A

Ureamic frost

21
Q

What is chronic constrictive pericarditis?

A

Thickening and fibrosis of the pericardium leading to restricts of filling of the heart.

22
Q

What are the causes of chronic constrictive pericarditis?

A 
Viral infection
Tuberculosis
Mediastinal radiotherapy
Mediastinal malignancy
Autoimmune disease
23
Q

In chronic constrictive pericarditis, which side of the heart is affected most initially?

A

The right side

24
Q

On examination, what signs might you find in someone with chronic constrictive pericarditis?

A

Raised JVP
Kussmaul’s sign - rise in JVP during inspiration
Rapid x and y descent of the JVP
Soft heart sounds
Irregularly irregular heart beat - AF is a common complication

25
Q

How might you use the JVP to differentiate between chronic constrictive and cardiac tamponade?

A

There is no x and y descent of the JVP in cardiac tamponade

26
Q

What investigations would you order for someone with suspected chronic constrictive pericarditis?

A 
Blood tests
Chest x-ray
ECG
Echo
Cardiac catheterisation
27
Q

What would the heart of a patient with chronic constrictive pericarditis look like on x-ray? What else might you see on the x-ray?

A

The heart size would actually be normal
There may be signs of a neoplasm or TB (seen as calcification)
Pleural effusions are not uncommon

28
Q

What might you find on cardiac catheterisation of a patient with chronic constrictive pericarditis?

A

Raised left and right end-diastolic pressures

Normal left ventricular function on ventriculogram

29
Q

How would you manage a patient with chronic constrictive pericarditis?

A

The only definitive treatment is pericardectomy

Antituberculous therapy if the underlying cause if found to be TB (continued for a year)

30
Q

What is a pericardial effusion?

A

An accumulation of fluid in the pericardial space.

31
Q

What are the causes of a pericardial effusion?

A 
Acute pericarditis
MI with ventricular wall rupture
Chest trauma
Cardiac surgery
Aortic dissection
Neoplasia
32
Q

How much fluid must collect in the pericardial sac for the patient to feel symptoms of pericardial effusion?

A

The volume is not the important thing. It is the rate at which the fluid appears. 2L that comes on slowly can be accommodated for without an increase in intrapericardial pressure. However, as little as 100mL can cause tamponade if it appears suddenly.

33
Q

What are the types of pericardial effusion?

A

Transudate
Exudate
Haemorrhagic

34
Q

What defines something as a transudative pericardial effusion?

A

Less than 30g of protein/L
A fluid to serum protein ratio of less than 0.5
A fluid to serum lactate dehydrogenase ratio of less than 0.6
A fluid to serum glucose ratio of more than 1.0

35
Q

What are some of the causes of a transudative pericardial effusion?

A 
Congestive heart failure
Hypoalbuminaemia
Hypothyroidism 
Radiation
Uraemia
36
Q

What defines something as an exudative pericardial effusion?

A

More than 30g of protein/L
Fluid to serum protein ratio of more than 0.5
A fluid to serum lactate dehydrogenase ratio of more than 0.6
A fluid to serum glucose ratio of less than 1.0

37
Q

What are some of the causes of an exudative pericardial effusion?

A 
Infection
Post MI
Malignancy
SLE
Dressler's syndrome
38
Q

What are some of the causes of a haemorrhagic pericardial effusion?

A 
Uraemia
Aortic dissection
Ventricular wall rupture
Trauma
Postcardiac surgery
39
Q

What are the symptoms associated with pericardial effusion with no cardiac tamponade?

A

Dull ache in the chest

Dysphagia

40
Q

What are the symptoms of cardiac tamponade?

A

Dyspnoea
Abdominal swelling (due to ascites)
Peripheral oedema

41
Q

On examination, what signs might you pick up in someone with a cardiac tamponade?

A 
Low blood pressure
Tachycardia
Pulsus paradoxus
Low volume pulse
Soft heart sounds
Low urine output
Raised JVP
42
Q

What investigations should be ordered for someone with suspected cardiac tamponade?

A

ECG
Chest x-ray
Echo

43
Q

What would the ECG of someone with cardiac tamponade show?

A

Small voltage complexes with variable axis (electrical alternans - caused by movement of heart within fluid)

CARDIOVASCULAR MEDICINE (15 decks)

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