Pericardium 1.29.18 Flashcards
Pericarditis differential diagnosis
- STEMI, NSTEMI
- pulmonary embolism
- heart failure
- pericardial effusion
- cardiac tamponade
- aortic dissection
- pneumothorax
- GERD
- Musculoskeletal pain/costochondritis
Name the layers of pericardium superficial to deep
- Fibrous pericardium
- serous layer
a. Parietal pericardium
~~~~pericardial fluid ~~~
b. Visceral pericardium
Pericardial cavity usually contains how much plasma ultrafiltrate?
15-50mL (about a shot glass worth)
Dressler’s syndrome
Post-cardiac injury immune response targeting the pericardium
What is the most common disorder of the pericardium?
Acute pericarditis
When is the peak time you might see acute pericarditis?
spring and fall (coincides with viral illnesses)
Acute pericarditis is often either idiopathic or viral infection. Which are two of the most likely viral offenders?
- Coxsackie virus B
2. Influenza
What is the main presenting symptoms in more than 95% of patients with acute pericarditis?
- Chest pain, improves with leaning forward
- radiation to the trapezius ridge is specific
worse with coughing, inspiration, lying flat
What is a highly specific physical exam finding for Acute pericarditis?
pericardial friction rub (scratchy, squeaky quality)
-Loudest at left sternal border
What is the most important ECG change in acute pericarditis?
Diffuse ST elevation!
-PR depression is highly specific but often overlooked
What will ECG acute pericarditis in stage 1 look like?
diffuse ST elevation and PR depression
What will ECG of acute pericarditis in stage 2 look like?
normalization of ST and PR
What will ECG of acute pericarditis in stage 3 look like?
diffuse, deep T wave inversions
What will ECG of acute pericarditis in stage 4 look like?
normalization
Name 3 differences between acute pericarditis and STEMI ECG
- ST elevation is diffuse
- ST is concave up
- No reciprocal changes
Using echocardiography what might you find if effusion present?
“swinging heart”
When should pericardiocentesis be peformed
if patient is not responding to medical therapy or if hemodynamic compromise
When should a biopsy be considered in pericarditis?
- illness lasting more than 3 weeks
- recurrent
What may labs look like in acute pericarditis?
- Elevated troponin
- CRP
- ESR
- WBC
If needing further workup and patient is not improving, what labs would you get (pericarditis)
- ANA
- Rheumatoid factor
- TB test
- HIV
- malignancy workup
What are the (4) diagnostic criteria of pericarditis? How many of these are needed to diagnose?
- Typical chest pain (sharp, pleuritic, improved with sitting up and leaning forward)
- Pericardial frictino rub
- Characteristic ECG changes (diffuse ST elevation)
- New/worsening pericardial effusion
NEED 2 OF THESE
High risk patients need to be admitted for pericarditis. Name some risk factors
*anticoagulants (may develop hemorrhagic effusion!)
- Trauma
- Fever
- Immunocompromised
Name 3 overal treatment goals for pericarditis
- Pain relief
- Resolve inflammation
- Prevent recurrence
What medication(s) is/are used to managed pericarditis?
NSAIDS +/- colchicine
When do you use glucocorticoids for pericarditis and why isn’t it first line treatment?
- used if NSAIDS are contraindicated
- glucocorticoids associated with higher recurrence rates
How long do you typically treat someone for pericarditis?
2 weeks or less
Pericardial effusion: clinical presentation
- chest pain/pressure/discomfort
- syncope
- palpitations
- respiratory symptoms: cough, dyspnea, hoarseness
*often discovered incidentally
How is the pain from pericardial effusion relieved?
sitting up and leading forward
How is the pain from pericardial effusion made worse?
lying flat
Pericardial effusion: physical exam findings?
- Pericardial friction rub
- elevated JVP
- tachycardia
- tachypnea
- decreased lung sounds at the bases (if concurrent with pleural effusion)
- hepatosplenomegaly
- weakened peripheral pulses
- edema
- cyanosis
What is the name for decrease in systolic blood pressure of more than 10mmHg with inspiration?
Pulsus paradoxus
-signals falling CO during inspiration
“water bottle” or “boot shaped” heart refer to what?
cardiomegaly
What are 2 more extreme ways to deal with recurrent cases of pericardial effusion?
- Repeat pericardiocentesis
2. Pericardiectomy
How long is a chronic pericardial effusion present?
3 months or more
Hemorrhagic pericardial effusion is most often caused by?
- Malignancy
- Iatrogenic (we caused it)
- MI complication
Cardiac Tamponade
compression of all 4 cardiac chambers due to increased pericardial pressure
Systemic venous return to the right side of the heart _____ with inspiration
increases
Pulmonary venous return to the left side of the heart_______ with inspiration
decreases
What does acute cardiac tamponade result in if untreated?
cardiogenic shock
Regional cardiac tamponade
localized hematoma compressing only selective chambers
Cardiac tamponade: what patient symptom is specific to cardiac tamponade
dyspnea
Also:
Tachypnea, sinus tachycardia, syncope, peripheral edema, chest discomfort
What are the three most imporant physical exam findings in a patient with cardiac tamponade?
Beck’s triad:
- Hypotension
- JVD
- Muffled heart sounds
What is Beck’s Triad?
Beck’s triad cardiac tamponade PE signs:
- Hypotension
- JVD
- Muffled heart sounds
When is Beck’s Triad usually observed?
acute cardiac tamponade
What are some ECG findings of cardiac tamponade?
- Electrical alternans (specific)
* Low voltage QRS (suggestion that this is only present with cardiac tamponade, not pericardial effusion)
What are 2 findings you would expect to find doing echocardiogram of cardiac tamponade?
- Diastolic collapse of the RV
2. IVC plethora (reflects marked elevation in central venous pressure)
What 2 factors affect hemodynamic effects of pericardial effusion?
- Size of effusion
2. Rate of fluid accumulation
What are 3 treatments to consider for cardiac tamponade?
- cardiology consult, hospital admission **
- Echo-guided pericardiocentesis (if hemodynamic compromise)
- Surgical drainage (also allows for biopsy)
What is typically the cause of pericarditis?
viral infection
Diagnosis of pericarditis and cardiac tamponade are usually _____?
clinical
What are pericarditis and pericardial effusion treated with?
NSAIDs + colchicine
Constrictive pericarditis: definition
Scarring and loss of normal elasticity of the pericardial sac (thickened, rigid)
What is a main distinguisher between tamponade and constrictive pericarditis?
tamponade has respiratory variation: systemic venous return can increase with inspiration
constrictive pericarditis: Systemic venous return can’t increase with inspiration
Most common presentation of constrictive pericarditis
symptoms of heart failure (peripheral edema, anasarca)
other symptoms: dyspnea, chest pain
Constrictive pericarditis: physical exam
- Elevated JVP**
- Pulsus paradoxus
- Kussmaul’s Sign
Kussmaul’s Sign
lack of inspiratory decline in JVP with inspiration
Pericardial “knock”
abnormal heart sound heard slightly earlier than S3
What is the difference between carotid pulse and internal jugular vein pulse?
Carotid pulse is ONE brisk upstroke
Internal Jugular Vein: “doube pulsation”
What is a highly specific finding for constrictive pericarditis on CXR?
pericardial calcification
can also see this on CT
How long is a trial of conservative treatment considered before pericardiectomy is recommended?
2-3 months (ex. diuretics)
(if constriction isn’t transient: pericardiectomy is the only definitive treatment
Which has poorer prognosis:; radiation-induced constrictive pericarditis or idiopathic?
radiation-induced is associated with poort outcomes
Which is more likely if a patient has amyloidosis:
Restrictive cardiomyopathy or constrictive pericarditis?
amyloidosis = restrictive cardiomyopathy more likely
Is a pericardial knock more likely Restrictive CM or constrictive pericarditis?
constrictive pericarditis = pericardial knock
