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Foundations of Clinical Practice II > Pericardium 1.29.18 > Flashcards

Pericardium 1.29.18 Flashcards

1
Q

Pericarditis differential diagnosis

A
  • STEMI, NSTEMI
  • pulmonary embolism
  • heart failure
  • pericardial effusion
  • cardiac tamponade
  • aortic dissection
  • pneumothorax
  • GERD
  • Musculoskeletal pain/costochondritis
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2
Q

Name the layers of pericardium superficial to deep

A
  1. Fibrous pericardium
  2. serous layer
    a. Parietal pericardium
    ~~~~pericardial fluid ~~~
    b. Visceral pericardium
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3
Q

Pericardial cavity usually contains how much plasma ultrafiltrate?

A

15-50mL (about a shot glass worth)

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4
Q

Dressler’s syndrome

A

Post-cardiac injury immune response targeting the pericardium

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5
Q

What is the most common disorder of the pericardium?

A

Acute pericarditis

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6
Q

When is the peak time you might see acute pericarditis?

A

spring and fall (coincides with viral illnesses)

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7
Q

Acute pericarditis is often either idiopathic or viral infection. Which are two of the most likely viral offenders?

A
  1. Coxsackie virus B

2. Influenza

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8
Q

What is the main presenting symptoms in more than 95% of patients with acute pericarditis?

A
  • Chest pain, improves with leaning forward
  • radiation to the trapezius ridge is specific

worse with coughing, inspiration, lying flat

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9
Q

What is a highly specific physical exam finding for Acute pericarditis?

A

pericardial friction rub (scratchy, squeaky quality)

-Loudest at left sternal border

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10
Q

What is the most important ECG change in acute pericarditis?

A

Diffuse ST elevation!

-PR depression is highly specific but often overlooked

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11
Q

What will ECG acute pericarditis in stage 1 look like?

A

diffuse ST elevation and PR depression

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12
Q

What will ECG of acute pericarditis in stage 2 look like?

A

normalization of ST and PR

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13
Q

What will ECG of acute pericarditis in stage 3 look like?

A

diffuse, deep T wave inversions

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14
Q

What will ECG of acute pericarditis in stage 4 look like?

A

normalization

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15
Q

Name 3 differences between acute pericarditis and STEMI ECG

A
  1. ST elevation is diffuse
  2. ST is concave up
  3. No reciprocal changes
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16
Q

Using echocardiography what might you find if effusion present?

A

“swinging heart”

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17
Q

When should pericardiocentesis be peformed

A

if patient is not responding to medical therapy or if hemodynamic compromise

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18
Q

When should a biopsy be considered in pericarditis?

A
  • illness lasting more than 3 weeks

- recurrent

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19
Q

What may labs look like in acute pericarditis?

A
  • Elevated troponin
  • CRP
  • ESR
  • WBC
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20
Q

If needing further workup and patient is not improving, what labs would you get (pericarditis)

A
  • ANA
  • Rheumatoid factor
  • TB test
  • HIV
  • malignancy workup
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21
Q

What are the (4) diagnostic criteria of pericarditis? How many of these are needed to diagnose?

A
  1. Typical chest pain (sharp, pleuritic, improved with sitting up and leaning forward)
  2. Pericardial frictino rub
  3. Characteristic ECG changes (diffuse ST elevation)
  4. New/worsening pericardial effusion

NEED 2 OF THESE

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22
Q

High risk patients need to be admitted for pericarditis. Name some risk factors

A

*anticoagulants (may develop hemorrhagic effusion!)

  • Trauma
  • Fever
  • Immunocompromised
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23
Q

Name 3 overal treatment goals for pericarditis

A
  1. Pain relief
  2. Resolve inflammation
  3. Prevent recurrence
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24
Q

What medication(s) is/are used to managed pericarditis?

A

NSAIDS +/- colchicine

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25
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
26
How long do you typically treat someone for pericarditis?
2 weeks or less
27
Pericardial effusion: clinical presentation
- chest pain/pressure/discomfort - syncope - palpitations - respiratory symptoms: cough, dyspnea, hoarseness *often discovered incidentally
28
How is the pain from pericardial effusion relieved?
sitting up and leading forward
29
How is the pain from pericardial effusion made worse?
lying flat
30
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
31
What is the name for decrease in systolic blood pressure of more than 10mmHg with inspiration?
Pulsus paradoxus -signals falling CO during inspiration
32
"water bottle" or "boot shaped" heart refer to what?
cardiomegaly
33
What are 2 more extreme ways to deal with recurrent cases of pericardial effusion?
1. Repeat pericardiocentesis | 2. Pericardiectomy
34
How long is a chronic pericardial effusion present?
3 months or more
35
Hemorrhagic pericardial effusion is most often caused by?
1. Malignancy 2. Iatrogenic (we caused it) 3. MI complication
36
Cardiac Tamponade
compression of all 4 cardiac chambers due to increased pericardial pressure
37
Systemic venous return to the right side of the heart _____ with inspiration
increases
38
Pulmonary venous return to the left side of the heart_______ with inspiration
decreases
39
What does acute cardiac tamponade result in if untreated?
cardiogenic shock
40
Regional cardiac tamponade
localized hematoma compressing only selective chambers
41
Cardiac tamponade: what patient symptom is specific to cardiac tamponade
dyspnea Also: Tachypnea, sinus tachycardia, syncope, peripheral edema, chest discomfort
42
What are the three most imporant physical exam findings in a patient with cardiac tamponade?
Beck's triad: 1. Hypotension 2. JVD 3. Muffled heart sounds
43
What is Beck's Triad?
Beck's triad cardiac tamponade PE signs: 1. Hypotension 2. JVD 3. Muffled heart sounds
44
When is Beck's Triad usually observed?
acute cardiac tamponade
45
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)
46
What are 2 findings you would expect to find doing echocardiogram of cardiac tamponade?
1. Diastolic collapse of the RV | 2. IVC plethora (reflects marked elevation in central venous pressure)
47
What 2 factors affect hemodynamic effects of pericardial effusion?
1. Size of effusion | 2. Rate of fluid accumulation
48
What are 3 treatments to consider for cardiac tamponade?
1. cardiology consult, hospital admission ** 2. Echo-guided pericardiocentesis (if hemodynamic compromise) 3. Surgical drainage (also allows for biopsy)
49
What is typically the cause of pericarditis?
viral infection
50
Diagnosis of pericarditis and cardiac tamponade are usually _____?
clinical
51
What are pericarditis and pericardial effusion treated with?
NSAIDs + colchicine
52
Constrictive pericarditis: definition
Scarring and loss of normal elasticity of the pericardial sac (thickened, rigid)
53
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
54
Most common presentation of constrictive pericarditis
symptoms of heart failure (peripheral edema, anasarca) | other symptoms: dyspnea, chest pain
55
Constrictive pericarditis: physical exam
- Elevated JVP** - Pulsus paradoxus - Kussmaul's Sign
56
Kussmaul's Sign
lack of inspiratory decline in JVP with inspiration
57
Pericardial "knock"
abnormal heart sound heard slightly earlier than S3
58
What is the difference between carotid pulse and internal jugular vein pulse?
Carotid pulse is ONE brisk upstroke Internal Jugular Vein: "doube pulsation"
59
What is a highly specific finding for constrictive pericarditis on CXR?
pericardial calcification | can also see this on CT
60
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
61
Which has poorer prognosis:; radiation-induced constrictive pericarditis or idiopathic?
radiation-induced is associated with poort outcomes
62
Which is more likely if a patient has amyloidosis: | Restrictive cardiomyopathy or constrictive pericarditis?
amyloidosis = restrictive cardiomyopathy more likely
63
Is a pericardial knock more likely Restrictive CM or constrictive pericarditis?
constrictive pericarditis = pericardial knock

Foundations of Clinical Practice II (25 decks)

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