STEPUP Cardiovascular System: Pericardial Diseases

Question 1

What is acute pericarditis?

Answer 1

Inflammation of the pericardial sac - may be an isolated finding or part of an underlying disorder or generalized disease

Question 2

What is the most likely cause of idiopathic pericarditis? What are examples of infectious causes? After how long post-MI can pericarditis occur? What are other causes?

Answer 2

1) Idiopathic (probably postviral): Most cases of idiopathic pericarditis are presumed to be postviral, usually preceded by a recent flulike illness or by upper respiratory or GI symptoms
2) Infectious: Viral (e.g., Coxsackievirus, echovirus, adenovirus, EBV, influenza, HIV, hepatitis A or B), bacterial (tuberculosis), fungal, toxoplasmosis
3) Acute MI (first 24 hours after MI)
4) Uremia
5) Collagen vascular diseases (e.g., SLE, scleroderma, rheumatoid arthritis, sarcoidosis)
6) Neoplasm - esepcially Hodgkin lymphoma, breast, and lung cancers
7) Drug-induced lupus syndrome (procainamide, hydralazine)
8) After MI: (Dressler syndrome) - usually weeks to months after MI
9) After surgery - postpericardiotomy syndrome
10) Amyloidosis
11) Radiation
12) Trauma

Question 3

How long does it take for the majority of patients to recover from acute pericarditis? How long does it take a minority of patients?

Answer 3

1) The majority recover within 1 to 3 weeks

2) A minority have a prolonged course or recurrent symptoms

Question 4

What are complications of acute pericarditis? In what percentage of patients can cardiac tamponade occur in?

Answer 4

1) Pericardial effusion

2) Cardiac tamponade - can occur in up to 15% of patients; close observation is important

Question 5

What is the most common symptom of acute pericarditis? What vital sign and laboratory study may be elevated? What information may a patient give about the history? What may be heard on auscultation of the heart?

Answer 5

1) Chest pain (most common finding)
2) Fever and leukocytosis may be present
3) Patient may give symptoms of preceding viral illness such as a nonproductive cough or diarrhea
4) Pericardial friction rub

Question 6

Describe the chest pain found in acute pericarditis. Where is it found and where does it radiate to? Does position affect the pain? If so, what position? How is the pain relieved?Is the pain always present?

Answer 6

1) Often severe and pleuritic (can differentiate from pain of MI because of association with breathing)
2) Localized to the retrosternal and left precordial regions and radiates to the trapezius ridge and neck
3) Pain is positional: It is aggravated by lying supine, coughing, swallowing, and deep inspiration
4) Pain is relieved by sitting up and leaning forward
5) Pain is not always present, depending on the cause (e.g., usually absent in rheumatoid pericarditis)

Question 7

Is the pericardial friction rub always present in acute pericarditis? How is it useful if you hear it? What is it caused by? What does it sound like? What are the components of the sound?

Answer 7

1) Not always present
2) It is very specific for pericarditis
3) Caused by friction between visceral and parietal pericardial surfaces
4) Scratching, high-pitched sound with up to three components. Patients may have any or all three of the components:
a) Atrial systole (presystolic)
b) Ventricular systole (loudest and most frequently heard)
c) Early diastole

Question 8

When is a pericardial friction rub heard best in pericarditis? Can it change over the course of the illness?

Answer 8

1) Heard best during expiration with patient sitting up and with stethoscope placed firmly against the chest
2) Friction rub may come and go over a period of several hours, and can vary greatly in intensity

Question 9

How is the diagnosis of acute pericarditis made?

Answer 9

1) ECG

2) Echocardiogram if pericarditis with effusion is suspected, but echocardiogram is often normal

Question 10

What are the four changes in sequence of an ECG in acute pericarditis?

Answer 10

1) Diffuse ST elevation and PR depression
2) ST segment returns to normal - typically around 1 week
3) T wave inverts - does not occur in all patients
4) T wave returns to normal

Question 11

What is the treatment for most cases of acute pericarditis? What are the mainstays of therapy for pain and other systemic symptoms? What may be tried if pain does not respond to this medication? When do you need to be hospitalized for acute pericarditis?

Answer 11

1) Most cases are self-limited and resolve in 2 to 6 weeks. Treat the underlying cause if known
2) NSAIDs are the mainstay of therapy (for pain and other systemic symptoms). Colchicine is also often used
3) Glucocorticoids may be tried if pain does not respond to NSAIDs, but should be avoided if at all possible
4) Relatively uncomplicated cases can be treated as an outpatient. However, patients with more worrisome symptoms such as fever and leukocytosis and patients with worrisome features such as pericardial effusion should be hospitalized

Question 12

Why does constrictive pericarditis occur?

Answer 12

Fibrous scarring of the pericardium leads to rigidity and thickening of the pericardium, with obliteration of the pericardial cavity

Question 13

What is constrictive pericarditis? Why is ventricular filling unimpeded during early diastole? When is ventricular filling halted abruptly? How does this contrast to cardiac tamponade?

Answer 13

1) A fibrotic, rigid pericardium restricts the diastolic filling of the heart
2) Ventricular filling is unimpeded during early diastole because intracardiac volume has not yet reached the limit defined by the stiff pericardium
3) When intracardiac volume reaches the limit set by the noncompliant pericardium, ventricular filling is halted abruptly
4) In contrast, ventricular filling is impeded throughout diastole in cardiac tamponade

Question 14

What is the most common cause of constrictive pericarditis? What are other causes?

Answer 14

1) In most patients, the cause is never identified and is idiopathic or related to a previous viral infection
2) Other causes include uremia, radiation therapy, tuberculosis, chronic pericardial effusion, tumor invasion, connective tissue disorders, and prior surgery involving the pericardium

Question 15

How do patients with constrictive pericarditis appear? What are three typical presentations of constrictive pericarditis?

Answer 15

1) Appear very ill
2) a) With symptoms characteristic of fluid overload such as edema, ascites, and pleural effusions
b) With symptoms related to the diminished cardiac output such as dyspnea on exertion, fatigue, decreased exercise tolerance, and cachexia
c) Patient can present with a combination of both of these findings

Question 16

What is the most common sign of constrictive pericarditis? What is Kussmaul sign? What is a pericardial knock? What two other signs are present?

Answer 16

1) JVD - most prominent physical finding; central venous pressure (CVP) is elevated and displays prominent x and y descents
2) Kussmaul sign - JVD (venous pressure) fails to decrease during inspiration
3) Pericardial knock - corresponding to the abrupt cessation of ventricular filling
4) Ascites
5) Dependent edema

Question 17

How may you distinguish constrictive pericarditis from restrictive cardiomyopathy?

Answer 17

May require echo or cardiac catheterization to distinguish these entities

Question 18

How do you diagnose constrictive pericarditis?

Answer 18

1) ECG
2) Echocardiogram
3) CT scan and MRI
4) Cardiac catheterization

Question 19

What does ECG show for constrictive pericarditis? When does AFib occur in the setting of constrictive pericarditis?

Answer 19

1) Nonspecific changes such as low QRS voltages, generalized T-wave flattening or inversion, left atrial abnormalities
2) AFib is more often seen in advanced disease but overall occurs in fewer than half of all patients

Question 20

What two things are seen on echo of constrictive pericarditis?

Answer 20

1) Increased pericardial thickness is seen in about half of all patients
2) A sharp halt in ventricular diastolic filling and atrial enlargement can also be seen

Question 21

What do CT scan and MRI show in constrictive pericarditis?

Answer 21

They may show pericardial thickening and calcifications, and can aid greatly in the diagnosis

Question 22

What does cardiac catheterization show in the chambers of the heart in constrictive pericarditis? What does the ventricular pressure tracing show?

Answer 22

1) Elevated and equal diastolic pressures in all chambers
2) Ventricular pressure tracing shows a rapid y descent, which has been described as a dip and plateau or a “square root sign”

Question 23

How do you treat constrictive pericarditis? What may be extremely helpful in treating fluid overload symptoms? What may necessary as treatment (in most cases)?

Answer 23

1) Treat the underlying condition
2) Diuretics
3) Surgical pericardiectomy

Question 24

Often, what does constrictive pericarditis progress to? What is indicated in most cases?

Answer 24

1) Worsening cardiac output and to hepatic and/or renal failure
2) Surgical treatment is indicated in most cases

Question 25

What is the imaging study of choice for diagnosis of pericardial effusion and cardiac tamponade? Why?

Answer 25

1) Echocardiogram

2) Has a high sensitivity

Question 26

What is pericardial effusion? In what setting can it occur in association with ascites and pleural effusion? Is it symptomatic? Is it acute or chronic?

Answer 26

1) Defined as any cause of acute pericarditis that can lead to exudation of fluid into the pericardial space
2) Can occur in association with ascites and pleural effusion in salt and water retention states such as CHF, cirrhosis, and nephrotic syndrome
3) Is often asymptomatic and suspected based on the symptoms of the underlying conditions
4) May be acute or chronic

Question 27

Are physical examination signs specific for diagnosis pf pericardial effusion? What are examples of physical exam signs?

Answer 27

All physical examination signs are extremely nonspecific and often do not aid in the diagnosis but may include:

a) Muffled heart sounds
b) Soft PMI
c) Dullness at the left lung base (because it may be compressed by pericardial fluid)
d) Pericardial friction rub may or may not be present

Question 28

How is the diagnosis of pericardial effusion made?

Answer 28

1) Echocardiogram
2) CXR
3) ECG
4) CT scan or MRI - very accurate, but often unnecessary given the accuracy of an echocardiogram
5) Pericardial fluid analysis

Question 29

What is the imaging procedure of choice for pericardial effusion? Why? In which patients should it be performed in?

Answer 29

1) Echocardiogram because it confirms the presence or absence of a significant effusion
2) Most sensitive and specific method of determining whether pericardial fluid is present; can show as little as 20 mL of fluid
3) Should be performed in all patients with acute pericarditis to rule out an effusion

Question 30

What does a CXR show for pericardial effusion? What is the typical appearance? What is suggestive of pericardial effusion?

Answer 30

1) CXR shows enlargement of cardiac silhouette when >250 mL of fluid has accumulated
2) Cardiac silhouette may have prototypical “water bottle” appearance
3) An enlarged heart without pulmonary vascular congestion suggests percardial effusion

Question 31

What does an ECG show in pericardial effusion? What does electrical alternans suggest?

Answer 31

1) Shows low QRS voltages and T-wave flattening but should not be used to diagnose pericardial effusion
2) Electrical alternans suggests a massive pericardial effusion and tamponade

Question 32

What may a pericardial fluid analysis be used for? What should you order within the analysis?

Answer 32

1) May clarify the cause of the effusion
2) Order protein and glucose content, cell count and differential, cytology, specific gravity, hematocrit, Gram stain, acid-fast stains, fungal smear, cultures, LDH content

Question 33

What does treatment for pericardial effusion depend on? When is pericardiocentesis indicated? What should you do if the effusion is small and clinically insignificant?

Answer 33

1) Depends on the patient’s hemodynamic stability
2) Pericardiocentesis is not indicated unless there is evidence of cardiac tamponade. Analysis of pericardial fluid can be useful if the cause of the effusion is unknown
3) A repeat echocardiogram in 1 to 2 weeks is appropriate

Question 34

What is a cardiac tamponade defined as? Is the rate of fluid accumulation or the amount of fluid more important? How many milliliters of fluid does it take to cause cardiac tamponade? Why is this so?

Answer 34

1) Accumulation of pericardial fluid
2) The rate of fluid accumulation
3) a) Two hundred milliliters of fluid that develops rapidly (i.e., blood secondary to trauma) can cause cardiac tamponade
b) Two liters of fluid may accumulate slowly before cardiac tamponade occurs
4) When fluid accumulates slowly, the pericardium has the opportunity to stretch and adapt to the increased volume (i.e., related to a malignancy)

Question 35

How does cardiac tamponade work? What is it characterized by? What happen to pressure in the atria, ventricles, pulmonary artery, and pericardium? When is ventricular filling impaired? What does decreased diastolic filling lead to?

Answer 35

1) Pericardial effusion that mechanically impairs diastolic filling of the heart
2) Characterized by the elevation and equalization of intracardiac and intrapericardial pressures
3) They equalize during diastole
4) During diastole
5) Decreased stroke volume and decreased cardiac output

Question 36

What are causes of cardiac tamponade and examples of each?

Answer 36

1) Penetrating (less commonly blunt) trauma to the thorax, such as gunshot and stab wounds
2) Iatrogenic: Central-line placement, pacemaker insertion, pericardiocentesis, etc.
3) Pericarditis: Idiopathic, neoplastic, or uremic
4) Post-MI with free wall rupture

Question 37

Why is pericardial effusion important clinically when it develops rapidly?

Answer 37

It may lead to cardiac tamponade

Question 38

What is the most common finding in cardiac tamponade? What are the venous waveforms present?

Answer 38

1) Elevated jugular venous pressure is the most common finding (distended neck veins)
2) Prominent x descent with absent y descent is seen

Question 39

What happens to the pulse pressure in cardiac tamponade? What is pulsus paradoxus? How can pulsus paradoxus be detected? When does the pulse get strong and when does it get weak?

Answer 39

1) Narrowed due to decreased stroke volume
2) Exaggerated decrease in arterial pressure during inspiration (> 10mm Hg drop)
3) Can be detected by a decrease in the amplitude of the femoral or carotid pulse during inspiration
4) Pulse gets strong during expiration and weak during inspiration

Question 40

What do heart sounds sound like in cardiac tamponade? What happens to the vital signs with the onset of cardiogenic shock?

Answer 40

1) Distant (muffled) heart sounds

2) Tachypnea, tachycardia, and hypotension with onset of cardiogenic shock

Question 41

What happen to heart pressures in cardiac tamponade?

Answer 41

Pressures in the RV, LV, RA, LA, pulmonary artery, and pericardium equalize during diastole

Question 42

What is Beck’s triad of cardiac tamponade?

Answer 42

1) Hypotension
2) Muffled heart sounds
3) JVD

Question 43

How is the diagnosis of cardiac tamponade made?

Answer 43

1) Echocardiogram
2) CXR
3) ECG
4) Cardiac catheterization

Question 44

What is the most sensitive and specific noninvasive test for cardiac tamponade? When must it be performed?

Answer 44

Echocardiogram must be performed if suspicion of tamponade exists based on history/examination and it is usually diagnostic

Question 45

What two things does CXR show for cardiac tamponade?

Answer 45

1) Enlargement of cardiac silhouette when > 250mL has accumulated
2) Clear lung fields

Question 46

What does ECG show for cardiac tamponade? Are findings sensitive or specific and should this test be used to diagnose tamponade?

Answer 46

1) Electrical alternans (alternate beat variation in the direction of the ECG waveforms) - due to pendular swinging of the heart within the pericardial space, causing a motion artifact
2) Findings are neither 100% sensitive nor specific. ECG should not be used to diagnose tamponade

Question 47

What does cardiac catheterization show in cardiac tamponade?

Answer 47

1) Shows equalization of pressures in all chambers of the heart
2) Shows elevated right atrial pressure with loss of the y descent

Question 48

What is the treatment of nonhemorrhagic tamponade if the patient is hemodynamically stable? If the patient is not hemodynamically stable?

Answer 48

1) a) Monitor closely with echocardiogram, CXR, ECG
b) If patient has known renal failure, dialysis is more helpful than pericardiocentesis
2) a) Pericardiocentesis is indicated
b) If no improvement is noted, fluid challenge may improve symptoms

Question 49

What is the treatment of hemorrhagic tamponade secondary to trauma? Should pericardiocentesis be used?

Answer 49

1) If the bleeding is unlikely to stop on its own, emergent surgery is indicated to repair the injury
2) Pericardiocentesis is only a temporizing measure and is not definitive treatment. Surgery should not be delayed to perform pericardiocentesis