#16 - Pericardial Disease. (Dr. Brown) Flashcards
How does angina (myocardial infarction pain) differ from acute pericarditis pain? Why?
Pericarditis pain simulates MI pain with one additional symptom: radiation to the left trapezius ridge. (because it irritates the diaphragm, phrenic nerve radiation)
-pain also gets WORSE lying flat, gets BETTER sitting up or leaning forward, and WORSE with inspiration
What are the physical exam signs for acute pericarditis?
1- the pericardial rub. It is sometimes 3 component (systole, early diastole, late diastole), sometimes 2 component (early diastole missing) and sometimes 1 component (just systole, can be mistaken for systolic murmur)
Pericardial rub is best heard along the left sternal border.
What are the labs to get (and the laboratory signs) of acute pericarditis?
- EKG - classic signs in 50% of cases.
- WBC/ ESR/ CRP - increased (inflammation)
- Troponin - normal most cases but can be slightly elevated.
- Echocardiogram - detects any effusion (lack of effusion does not rule out acute pericarditis!)
What is the clinical course of pericardial disease?
-it is usually benign, but sometimes, acute pericarditis can turn into cardiac tamponade or, given lot of time for fibrosis, chronic constrictive pericaditis.
What is acute pericarditis?
inflammation of the sac surrounding the heart, the pericardium, usually lasting less than 6 weeks
What is pericardial effusion with cardiac tamponade
Pericardial effusion = fluid in the pericardial sac.
Cardiac tamponade means it has built up enough to compress the heart. This affects stroke volume, causing hypotension, SOB on exertion, narrow pulse pressure..
What is the “paradoxical pulse” and when is it found?
It is when the systolic pressure during inhalation is more than 10 mmHg lower than in exhalation. It is found nearly always in cardiac tamponade.
Why does paradoxical pulse occur?
Inspiration normally creates a little bit of systolic pressure drop. However, in cardiac tamponade, the inspiration causes the same increase of blood return into the right atrium and ventricle, increasing their volume. Because the total heart volume is fixed due to the fluid filled pericardium, this expansion compresses the left heart chambers, resulting in a marked decrease of LV stroke volume. This drop in stroke volume causes the subsequent drop in systolic BP during inspiration.
What are the physical exam findings of cardiac tamponade?
- dyspnea
- orthopnea (SOB when laying down)
- hypotension (low systolic pressure)
- paradoxical pulse
- jugular venous distension.
- NO Kussmaul’s sign
- no pulmonary rales/crackles.
- pericardial rub may or may not be present.
How do atrial pressure and intrapericardial pressure relate to the “Paradoxical pulse”/hypotension observed in cardiac tamponade?
Figure: atrial pressure and intrapericardial pressures usually mirror each other.
as more fluid is added to the pericardial sac, the pressure of both rise.
At the point where their pressure is equal to the blood pressure, blood pressure
starts to drop precipitously. This is the point of danger where you must diagnose and
treat before they die.
What labs should be ordered for cardiac tamponade?
- Get an immediate Echocardiogram!! Crucial piece.
- Pericardiocentesis (aspiration of pericardial fluid) also key to treatment and diagnosis of why the tamponade happened.
- EKG and Chest X ray are rarely helpful.
What is seen on X ray for cardiac tamponade?
-may see enlarged cardiac silhouette, but normal heart shadow does not exclude effusion/tamponade.
May look similar to enlargement seen in CHF.
What is the role of catheterization and pericardiocentesis for diagnosis and treatment of cardiac tamponade?
It is essential to both!!!
Define Kussmaul’s sign. In which condition(s) is it found?
it is an elevation of the jugular venous pulse during inspiration. It happens with constrictive pericarditis.
What is constrictive pericarditis?
The pericardium is fibrosed, allowing neither side of the heart to expand. Lack of expansion creates increased filling pressures, compromising SV and BP.
