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Pathophysiology - Cardiovascular > Clinical Pericardial Disease > Flashcards

Clinical Pericardial Disease Flashcards

1
Q

How does the intrapericardial pressure vary with respiration?

A

-5 mmHg with inspiration

+5 mmHg with expiration

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2
Q

What is the function of the pericardium, and is it critical?

A

Limits the acute distension of the heart, lubricates and anchors the heart, and prevents the spread of infection to the heart.

However, it has no major vital function and can be removed

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3
Q

What do the visceral and parietal pericardium rub against when inflamed? What can happen to these layers if chronically inflamed?

A

Visceral - the heart

Parietal - innervated, against the pleura

Chronic inflammation -> thickening and tightening, restricting cardiac filling

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4
Q

What are the clinical symptoms of acute pericarditis?

A

Sharp or rubbing chest pain which is pleuritic, meaning it varies with intensity of chest wall movement or position such as sitting or lying down

Can mimic MI: Fever, tachycardia, dyspnea

Will hear a three part friction rub

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5
Q

What is the first stage of ECG changes with acute pericarditis? Include PR, QRS, and ST changes.

A

PR - often early PR segment depression from atrial involvement

QRS - low amplitude due to decreased ability to contract from pericardial effusion

ST - ST elevation in almost all leads, except aVR. Would normally indicate infarct in all coronary arteries, but super unlikely. No reciprocal changes on any lead.

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6
Q

How does the ECG recover overtime from acute pericarditis?

A

J point will come down, T waves will decrease in amplitude, invert, then finally resolve

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7
Q

What will happen to WBC count, ESR, and cardiac enzymes in pericarditis? What should you think if the third is elevated w/o other signs of pericarditis

A

WBC count - Mild lymphocytosis (inflammation state)
ESR - will be increased (+APP), due to fibrinogen helping form Rouleaux stacks with WBC
Cardiac enzymes - Increased

If cardiac enzymes are elevated w/o pericarditis, think myocarditis or silent MI with subsequent pericarditis

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8
Q

What are the viral causes of pericarditis? Especially in AIDS? How do you treat?

A

Coxsackievirus, adenovirus, echovirus

AIDS - CMV

These are usually self limiting

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9
Q

What causes the majority of pericarditis?

A

Idiopathic

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10
Q

What are the possible complications of viral pericarditis?

A

Myocarditis is biggest worry -> can lead to heart failure

Also may recur, cause tamponade, or constrict

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11
Q

What is the most common cause of bacterial pericarditis today, and what organisms?

A

Seen post-operatively, often in conjunction with endocarditis and bacteremia

Common organisms: S. pneumoniae (if from pneumonia as in past), S. aureus, other streptococci

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12
Q

What is the most essential treatment for bacterial pericarditis?

A

Early surgical drainage via pericardiocentesis

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13
Q

What is Tuberculous pericarditis? Describe it.

A

Pericarditis caused by TB, spread from chest & lymph nodes causing a blood effusion

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14
Q

Who is most liable to getting tuberculous pericarditis? What does it progress to?

A

Most common in AIDS population, often progresses to constriction with calcification.

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15
Q

What immune-mediated connective tissue diseases can cause pericarditis?

A
  1. Systemic lupus erythematosus
  2. Rheumatoid arthritis
  3. Scleroderma (Systemic sclerosis)
  4. Mixed connective tissue disease
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16
Q

What arteritis’s can cause pericarditis?

A

Polyarteritis nodosa, and temporal arteritis

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17
Q

What is the pathophysiology of Dressler’s syndrome? What does it result in and how is it treated?

A

Typically weeks or months post MI, can cause pericardial / pleural effusions due to sensitization of immune system to myocardial cells during necrosis.

Often causes constriction. Usually self-limited, but may need NSAIDs or steroids

18
Q

What causes uremic pericarditis, and what is its typical progression? How is it treated?

A

Due to renal failure with accumulation of urea

Typically leads to slowly-accumulation pericardial effusion which can be accommodation, but may sometimes progress rapidly to tamponade

Treated via aggressive hemodialysis to filter urea

19
Q

What is malignant pericarditis and its most common causes?

A

Pericarditis caused by tumor or fluid from tumor, which can cause tamponade

Often causes by lung carcinoma, breast carcinoma, lymphoma (also sometimes melanoma)

20
Q

What is a common treatment for malignant pericarditis if it is very end-stage?

A

Surgically connect pericardial and pleural spaces for a “window” of drainage

21
Q

How is radiation-induced pericarditis difficult to treat?

A

Happens following radiation cancer treatment, difficult to treat because it leads to fibrotic change -> constriction, restriction, drainage of fluid may not relieve symptoms

22
Q

What drugs are commonly associated with pericarditis?

A
  1. Minoxidil - HF vasodilation
  2. Hydralazine (lupus-induced)
  3. Izoniazid
  4. Cyclosporine
23
Q

What thyroid cause can lead to pericarditis? How does device-related pericarditis happen?

A

Thyroid - hypothyroidism

Device-related - Pacemakers can perforate

24
Q

What are the congenital causes of pericarditis? What will these cause?

A
  1. Pericardial cyst - usually benign
  2. Congenital absence of pericardium -> risk of herniation of heart and sudden cardiac death, and possible coronary artery compression
25
Q

How does congenital absence of the pericardium appear on X-ray?

A

“Snoopy dog” cardiac silhouette with marked lack of definition of left heart border

26
Q

What is the general treatment for acute pericarditis?

A

2 weeks of NSAIDs for symptoms: Indomethacin or ibuprofen
Systemic steroids - if slow response
Colchicine - as an alternative to corticosteroids

27
Q

How should you treat recurrent pericarditis? Medically / surgically?

A

Avoid steroids. Start with NSAIDs again, but lean more on colchicine which has fewer side effects.

May indicate surgical treatment via pericardiectomy

28
Q

When is a pericardial effusion considered large? How does this look on X-ray?

A

When fluid is >2cm on echo.

X-ray = cardiac silhouette will appear rounded and flask-like

29
Q

What happens to heart sounds and ECG in a very large pericardial effusion?

A

Heart sounds - reduced intensity of friction rub

ECG - electrical alternans -> cyclically varying size of R waves as heart swings back and forth in fluid-filled pericardial cavity

30
Q

What is Ewart’s sign and why does it happen?

A

Dullness and decreased breath sounds with egophony (E sounds like an A) over posterior left lung

-> due to compression via large pericardial sac

31
Q

What are the clinical signs of pericardial tamponade? What causes this?

A

Elevated venous pressure - JVD, hepatomegaly, edema

Reflex tachycardia due to hypotension and cardiogenic shock
-> impaired diastolic filling as intrapericardial pressure exceeds ventricular diastolic pressure

Muffled heart sounds

32
Q

What happens to the pulse in pericardial tamponade? Why?

A

Pulsus paradoxus - defined as >10 mmHg drop in blood pressure in systolic BP during inspiration

Due to greatly increased venous return to RV in inspiration, RV pushes septum into LV which is diastolically constricted as is -> causes a massive drop in preload and increase in afterload, dropping stroke volume and systolic BP

33
Q

Does pulsus paradoxus happen in constrictive pericarditis? Why or why not?

A

No -> in constrictive pericarditis, the RV also struggles to fill in diastole, so the septae does not deviate and there is not a >10 mmHg drop in BP

34
Q

What are the features of tamponade on echo?

A

RA and RV diastolic collapse -> lowest pressure chambers, will collapse in early diastole before filling pressures bring it above pericardial sac

IVC “plethora” - very distended

35
Q

What are the treatments for tamponade?

A
  1. Pericardiocentesis

2. Surgical - fluid removal + biopsy to determine cause, or pericardiectomy

36
Q

What is the pathophys of constrictive pericarditis?

A

Fibrous thickening with adhesion to myocardium and calcification (concrete box for heart)

-> limits diastolic volume, looking like right-sided heart failure (elevated JVP, hepatomegaly, ascites, edema)

37
Q

What are the most common causes of constrictive pericarditis?

A

post-cardiac surgery, healing w/fibrosis
TB / infection
Irradiation
Foreign body (i.e. defibrillator pathces)
Uremia - as in CKD
Sarcoidosis

38
Q

What is Kussmaul’s sign? What causes it?

A

Sign of constrictive pericarditis -> rise in systemic VENOUS pressure during INSPIRATION (opposite normal)
-> due to increase in venous flow but no compliance of RV to accommodate increased venous volume (restrictive disease)

39
Q

What abnormal heart sound is associated with constrictive pericarditis? How is it told apart from S3?

A

Pericardial knock - due to early and abrupt cessation of ventricular filling

Happens in early diastole like S3, but it is higher frequency

40
Q

What is the medical and surgical management of constrictive pericarditis?

A

Medical - Diuretics and salt restriction (reduce volume overload)
Surgical - Pericardiectomy - only definitive treatment

Pathophysiology - Cardiovascular (24 decks)

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