B4.062 Big Case Pericarditis

Question 1

list the layers of the pericardium

Answer 1

fibrous pericardium (outermost)
parietal layer of serous pericardium
pericardial fluid
visceral layer of serous pericardium (innermost)
myocardium

Question 2

what structures attach to the fibrous pericardium to keep the heart in place

Answer 2

aorta
pulm artery and veins
IVC and SVC

Question 3

how much pericardial fluid is normal

Answer 3

20-33 ccs

Question 4

normal pericardial functions

Answer 4

attaches the heart to the thorax (prevents it from moving)
protective covering (shock absorber)
lubricant to decrease friction with heart beats
prevents excessive dilatation in situations of volume excess
helps with diastolic relaxation of the cardiac muscle

Question 5

typical time span of MI or angina

Answer 5

30 min- 6 hours max

Question 6

what are some identifying characteristics of GERD as a source of chest pain

Answer 6

association with food

worse when laying flat

Question 7

symptoms of aortic dissection

Answer 7

severe chest, neck, or back pain
can be ripping/tearing, but commonly sharp
abrupt and maximal in onset
nausea, vomiting, diaphoresis
syncope (5-10%)

Question 8

characterize the pain associated with pericarditis

Answer 8

mid sternal chest pain
sharp/ knife like
worse with deep inspiration/ cough
better when sitting
worse with laying supine
unrelenting (longer lasting than MI or angina)

Question 9

symptoms of acute pericarditis

Answer 9

pain
prodromal phase
fever
malaise
several days to weeks
dyspnea
fatigue

Question 10

physical exam findings associated with acute pericarditis

Answer 10

tachycardia
increased temp
pericardial rub

Question 11

discuss how to hear a pericardial rub

Answer 11

press stethoscope diaphragm firmly to the chest wall
may be exacerbated by deep inspiration
best heard when patient is sitting and leaning forward

Question 12

what does a pericardial rub sound like

Answer 12

Velcro like
leather rubbing
scratchy/superficial

Question 13

typical work up for acute pericarditis

Answer 13

blood work: troponins, CBC, ESR
CXR: rule out pneumonia, rub fracture
ECG
echo
other imaging: CT, MRI (usually not done)

Question 14

ECG findings with acute pericarditis

Answer 14

tachycardia
diffuse concave upward ST elevations
PR depressions
low voltage if large effusion present

Question 15

echo findings with acute pericarditis

Answer 15

cannot see inflamed pericardium

most have pericardial effusions (usually small, occasionally large)

Question 16

what imaging can be used to visualize the inflamed pericardium

Answer 16

MRI with contrast

Question 17

acute pericarditis diagnostic criterion

Answer 17

need 2 of 4 to diagnose

1. characteristic chest pain
2. pericardial friction rub
3. classic ECG changes
4. pericardial effusion

Question 18

acute pericarditis supportive criterion

Answer 18

evidence of systemic inflammation

pericardial inflammation on MRI/CT

Question 19

primary causes of acute pericarditis

Answer 19

idiopathic (85-90%)
infectious
neoplastic
autoimmune
MI

Question 20

major predictors of pericarditis severity

Answer 20

fever > 100.4
subacute onset
evidence suggestive of cardiac tamponade
large pericardial effusion
NSAIDs ineffective after 7 days

Question 21

minor predictors of pericarditis severity

Answer 21

immunosuppressed state
history of oral anticoagulation therapy
acute trauma
elevated cardiac troponin (suggestive of myopericarditis)

Question 22

mainstays of pericarditis treatment

Answer 22

restriction of physical activity for several weeks
NSAIDs
colchicine

Question 23

discuss the dosing of NSAIDs in pericarditis treatment

Answer 23

high dose (600-800 mg 4x daily)
4-6 weeks
gradually taper to reduce risk of recurrence
take w food to prevent damage to gastric mucosa

Question 24

when should you use corticosteroids for pericarditis

Answer 24

not first line
may increase risk of recurrence
NSAID intolerant patients
pericarditis secondary to rheumatologic disease

Question 25

what is colchicine

Answer 25

not an NSAID
concentrated in neutrophils and prevents their migration by disrupting microtubule polymerization
decreases inflammation
takes a few days to start working

Question 26

adverse effect of colchicine

Answer 26

diarrhea

Question 27

classification of pericarditis based on duration

Answer 27

acute: a few weeks (4-6 weeks)
incessant/intractable: >6 weeks
chronic: >3-6 months
recurrent: resolves but comes back after 4-6 weeks

Question 28

discuss the features of incessant pericarditis

Answer 28

may accumulate more fluid/tamponade

fluid may become exudative/organized

Question 29

follow ups for acute pericarditis

Answer 29

assess clinical response after 1 week

see in 3-4 weeks to taper NSAIDs if things are going well

Question 30

occurrence of recurrent pericarditis

Answer 30

15-30%

Question 31

reasons for recurrent pericarditis

Answer 31

unknown
autoimmune process maybe
more often in immunocompromised
may relate to: inadequate treatment of initial inflammation, initial use of corticosteroids

Question 32

management of recurrent pericarditis

Answer 32

look for etiology
exercise restriction
NSAID as prior
colchicine: weight based dose as high as tolerated, at least 6 months

Question 33

management of really intractable cases of recurrent pericarditis

Answer 33

IV immunoglobulins
azothiaprine
anakinra
make sure no infection

Question 34

last resort for pericarditis

Answer 34

surgical pericardiectomy

doesn’t always end recurrences bc some can be stuck to myocardium and remain

Question 35

complications of acute pericarditis

Answer 35

cardiac tamponade

constrictive pericarditis