8/21- Pericardial Diseases at the Bedside Flashcards Preview

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Flashcards in 8/21- Pericardial Diseases at the Bedside Deck (28):
1

Case)

- 65 yo woman admitted with progressively increasing abdominal girth and leg swelling of 5 mo duration

- Not previously known to have any cardiac disease

- PMH: Hodgkin's lymphoma diagnosed at 48 yo for which she received radiation therapy to chest, mediastinum, and abdomen (cured since without recurrence)

- BP = 114/86 (with decrease in SBP of 7 mmHg during normal inspiration)

- HEENT: distended jugular veins to 8 cm above Angle of Lewis with prominent steep early diastolic y descent; jugular veins did not collapse during inspiration

- Chest: clear lungs, quiet precordium with decreased S1 and S2, no murmurs. Possible early disatolic extrasound after S2 (no change with inspiration)

- Positive fluid waves in abdomen, large liver (nontender)

- 2+ pitting ankle and pretibial edema, no cyanosis, minimal clubbing

- Normal sinus rhythm on EKG

This pt has a clinical presentation consistent with:

A. Congestive heart failure

B. Gross volume overload

C. Evidence of chronically elevated RA pressures

D. All of the above

This pt has a clinical presentation consistent with:

A. Congestive heart failure

B. Gross volume overload

C. Evidence of chronically elevated RA pressures 

D. All of the above

2

What is/are common cause(s) of such a clinical presentation in an elderly pt in practice?

A. CHF due to CAD

B. CHF due to dilated cardiomyopathy

C. CHF due to longstanding HTN

D. Any of the above

What is/are common cause(s) of such a clinical presentation in an elderly pt in practice? 

A. CHF due to CAD 

B. CHF due to dilated cardiomyopathy 

C. CHF due to longstanding HTN 

D. Any of the above

3

What is the mechanism of a 7 mmHg drop in SBP with inspiration in this pt?

A. Decline in LV filling with septal bulging

B. Decline in RV filling with septal bulging

C. Lower LV SV

D. Lower SVR

E. A and C

What is the mechanism of a 7 mmHg drop in SBP with inspiration in this pt? 

A. Decline in LV filling with septal bulging 

B. Decline in RV filling with septal bulging 

C. Lower LV SV 

D. Lower SVR 

E. A and C

4

What is a pulsus paradoxus?

A. Paradoxical loss of pulse during inspiration

B. Drop in SBP > 10 mmHg during inspiration

C. Decrease in SBP under 10 mmHg during inspiration

D. None of the above

What is a pulsus paradoxus?

A. Paradoxical loss of pulse during inspiration 

B. Drop in SBP > 10 mmHg during inspiration

C. Decrease in SBP under 10 mmHg during inspiration

D. None of the above

5

Why did the jugular veins fail to collapse during inspiration?

A. Very high RA pressure prevents jugular vein emptying into RA

B. Restricted filling of the RV markedly raises the RA pressure

C. A and B

D. None of the above

Why did the jugular veins fail to collapse during inspiration? 

A. Very high RA pressure prevents jugular vein emptying into RA 

B. Restricted filling of the RV markedly raises the RA pressure

C. A and B

D. None of the above

6

What is the name of the sign regarding failure of the JV to collapse?

A. Pulsus paradoxus

B. Pulsus alternans

C. Kussmaul sign

D. Electrical alternans

E. Stubborn JV sign

What is the name of the sign regarding failure of the JV to collapse?

A. Pulsus paradoxus 

B. Pulsus alternans 

C. Kussmaul sign

D. Electrical alternans 

E. Stubborn JV sign

7

What causes the y-descent of the JV or RA pressure waveform?

A. Late ventricular filling

B. Early ventricular filling

C. Diastasis or slow ventricular filling

D. Isovolumic relaxation (IVR)

What causes the y-descent of the JV or RA pressure waveform?

A. Late ventricular filling

B. Early ventricular filling 

C. Diastasis or slow ventricular filling

D. Isovolumic relaxation (IVR)

8

What causes the STEEP y-descent in this patient?

A. Enhanced very early RV filling

B. Impaired early RV filling

C. Enhanced very early RA emptying

D. A and C

E. None of the above

What causes the STEEP y-descent in this patient? 

A. Enhanced very early RV filling 

B. Impaired early RV filling 

C. Enhanced very early RA emptying

D. A and C 

E. None of the above

9

What does x-descent mark in the atrial pressure waveform?

What does a steep x-descent result from?

X-descent: atrial relaxation

- Steep in pericardial disease

- Steep x-descent results from an elevated JVP

10

What causes the dip-and-plateau sign?

A. Enhanced very early filling followed by sudden halt in filling

B. Decreased very early RV filling followed by compensatory increased filling

C. None of the above

What causes the dip-and-plateau sign? 

A. Enhanced very early filling followed by sudden halt in filling 

B. Decreased very early RV filling followed by compensatory increased filling

C. None of the above

- Dip = enhanced early RV filling

- Plateau = reduced late RV filling

11

Do you expect a dip-and-plateau in this patient?

Yes

12

What is the most likely underlying cardiac disease to explain this patient's presentation?

A. Cardiac tamponade

B. Constrictive pericarditis

C. CHF due to CAD/HTN

D. DCM

What is the most likely underlying cardiac disease to explain this patient's presentation? 

A. Cardiac tamponade 

B. Constrictive pericarditis 

C. CHF due to CAD/HTN 

D. DCM

13

What is causing the early diastolic extra sound in this patient?

A. Loud P2

B. Loud S3 gallop

C. Prominent S4 gallop

D. Tumor plop

E. Pericardial knock

What is causing the early diastolic extra sound in this patient? 

A. Loud P2 

B. Loud S3 gallop

C. Prominent S4 gallop 

D. Tumor plop 

E. Pericardial knock

 - Early diastolic extra sound (K)

- Occurs shortly after S2 (may be confused with S3 gallop)

- Results from abrupt cessation or slowing of ventricular filling as the stiff pericardium limits expansion of the ventricle

14

Case 2)

- 43 yo woman

- Chronic smoker

- Admitted for SOB, weakness, and progressive weight loss of about 25 pounds in the last 3 mo

- 2 ya, diagnosed with stage III breast adenocarcinma and received 6 courses of chemo with good symptomatic response and drastic reduction in tumor mass. Complete remission could not be achieved

- PE: pale, weak, cachectic in mild distress

- BP = 85/55; no change during inspiration

- HR = 130/min (tachycardia)

- RR = 26/min

- Dry mucous membranes, decreased skin turgor, and pale conjunctiva

- HEENT: palpable hard supraclavicular and axillary LNs; normal carotid upstrokes. Markedly distended neck veins with steep x-descent and normal y-descent

- Clear lungs

- Quiet precordium with markedly decreased S1 and S2; no extrasounds

- ECG: NSR, fat rate, alternating large and small QRS complexes; decreased QRS complexes throughout  

What is the most likely cardiac disease in this patient?

A. Constrictive pericarditis

B. Cardiac tamponade

C. Heart failure

D. Dilated cardiomyopathy

E. Pericardial metastasis

Q image thumb

What is the most likely cardiac disease in this patient? 

A. Constrictive pericarditis

B. Cardiac tamponade 

C. Heart failure 

D. Dilated cardiomyopathy

E. Pericardial metastasis

15

Do you expect to detect > 10 mmHg drop in SBP during inspiration?

No; while this (pulsus paradoxus) is a hallmark of cardiac tamponade, it may not be seen in hypotensive pts like this one

- IV dependence -> shift of IV septum to LV with increased RV filling during inspiration -> Reduced LV EDV and SV (Frank Starling) and thus decreased SBP

16

Is pulsus paradoxus always present in cardiac tamponade?

No

- Severe hypotension/hypovolemia prevents rise in RV filling during inspiration and stops the whole cycle

- Volume replacement often facilitates its detection

17

Why is there alteration of large and small QRS complexes?

A. Movement of the heart within the pericardial sack

B. Severe dilated cardiomyopathy

C. A and B

D. None of the above

Why is there alteration of large and small QRS complexes? 

A. Movement of the heart within the pericardial sack

B. Severe dilated cardiomyopathy

C. A and B 

D. None of the above

18

What causes electrical alternans?

A. Swinging motion of the heart within the fluid-filled pericardial sac

B. Swinging motion of the pericardial fluid around the heart

C. Alternation of QRS complexes

D. A and C

What causes electrical alternans? 

A. Swinging motion of the heart within the fluid-filled pericardial sac 

B. Swinging motion of the pericardial fluid around the heart 

C. Alternation of QRS complexes 

D. A and C

... probably a better answer than C since C isn't a cause

- Electrical alternans is the alternating amplitude of the R wave from one complex to the next 

A image thumb
19

Why are diuretics not recommended in this patient?

A. BP of 85/55 and diuretics would drop the BP

B. Impaired LV filling is causing low BP

C. Distended neck veins are not due to CHF

D. All of the above

E. None of the above

Why are diuretics not recommended in this patient? 

A. BP of 85/55 and diuretics would drop the BP 

B. Impaired LV filling is causing low BP

C. Distended neck veins are not due to CHF 

D. All of the above

E. None of the above

20

Why is the y descent normal in this patient?

A. Steep Y descent is characteristic of constrictive pericarditis

B. Early RV filling is not enhanced

C. Early RA emptying is not increased

D. All of the above

Why is the y descent normal in this patient?

A. Steep Y descent is characteristic of constrictive pericarditis 

B. Early RV filling is not enhanced 

C. Early RA emptying is not increased 

D. All of the above

21

What is the most diagnostic bedside cardiac test in this patient?

A. Kussmaul sign

B. Pulsus paradoxus

C. Pulsus alternans

D. Electrical alternans

E. Loss of pulse with diuretic test dose

What is the most diagnostic bedside cardiac test in this patient? 

A. Kussmaul sign 

B. Pulsus paradoxus 

C. Pulsus alternans 

D. Electrical alternans 

E. Loss of pulse with diuretic test dose

22

What is the treatment of choice in this patient?

A. Pericardiectomy

B. Pericardiocentesis

C. Heart transplantation

D. Heart and lung transplantation

E. Cautious diuresis

What is the treatment of choice in this patient? 

A. Pericardiectomy 

B. Pericardiocentesis

C. Heart transplantation 

D. Heart and lung transplantation

E. Cautious diuresis

23

What is the clinical triad of cardiac tamponade?

1. Increased JVP

2. Low BP

3. Large* quiet heart

*Large heart usually with large pericardial effusion causing tamponade; if small effusions, may have small heart

24

T/F: equalization of elevated IC pressures is a hallmark of any pericardial disease causing impairment of diastolic filling

True

- Can occur with cardiac tamponade or constrictive pericarditis (or even restrictive CM)

RAP = RVEDP = RADP = PCWP = LAP = LVEDP

(All these pressures are measured in diastole when MV and TV are open)

25

What are causes of acute pericarditis?

- Idiopathic (most common)

- Infectious: bacterial (TB!, staph aureus, pneumo), viral, fungal, parasitic

- Irradiation (for Hodgkin's disease or other chest malignancies)

- CT disease: RA, SLE

- Post-hemopericardium (post-op, trauma)

- Uremia (ESRD)

- Neoplastic

26

What is the classic triad of acute pericarditis?

1. Sharp chest pain of pericarditis by Hx

2. Diffuse ST elevation by ECG

3. Pericardial rub sound by physical exam 

A image thumb
27

What is the chest pain of acute pericarditis like?

Sharp and positional

- Increases with inspiration and lying supine; improves by sitting up

28

How do you treat acute pericarditis?

- Non-steroidal anti-inflammatory drugs (NSAIDs)

- Steroids (prednisone)