9 - Pericardial Disease Flashcards

1
Q

Pericardial fluid

A

Normal 15-50ml

Pathologic 200-250ml

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2
Q

Purpose of pericardium

A

Immobilization of the heart
Prevents extreme dilation of heart (intracardiac volume raise)
Limits spread of infection

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3
Q

Acute Pericarditis

A

Acute inflammation of pericardium due to individual cause or systemic disease

  • pleuritic chest pain (95%)
  • EKG changes
  • pericardial friction rub
  • fever (+/-)
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4
Q

Acute pericarditis infectious causes

A
Idiopatihic/viral (most common)
-coxsackie 
-CMV
-Herpes
-HIV
Bacterial 
TB
Fungal
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5
Q

Acute paracarditis non-infectious

A
Post MI
Post cardiac surg
Metabolic
Neoplasm
Connective tissue disease
Drug induced
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6
Q

Drug induced pericarditis

A

Drug induced SLE like syndrome

  • hydralazine (resistant HTN)
  • methyldopa (pregnancy HTN)
  • isoniazid (INH)
  • phenytonin
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7
Q

Acute Pericarditis pathogenesis stages

A
  1. Local vasodilation w transudation fluid into pericardial sack
  2. Increased vascular permeability
  3. Leukocyte exudation
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8
Q

Acute pericarditis pathogenesis line of badness

A

Causative agent -> local vasodilation -> increased vascular permeability -> infiltration of pericardiumj w leukocyte exudate -> deposition of fibrin -> inflammation -> rub/pain

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9
Q

Pericarditis highest mortality?

A

Purulent pericarditis has almost 50% mortality

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10
Q

Acute pericarditis pathophysiology

A

Serous: thin exudate
Serofibrinous: bread and butter (yellow exudate, looks rough and shaggy)
Suppurative: bacterial (purulent)
Hemorrhagic: TB/Cancer (bloody)

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11
Q

Clinical manifestations of acute pericarditis

A
Chest pain 95%
-“pleuritic”
Friction rub (highly specific)
ECG changes (90% are abnormal)
-new widespread/diffuse st elevations maybe PR depression
Fever
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12
Q

Acute pericarditis HX

L-OPQRST

A
Location - retrosternal
Onset - sudden (hours/days)
Palliative - sitting up/leaning forward
Quality - goes up w provocative maneuvers
Radiation - to trapezius ridge and neck
Severity - varied
Timing - worse w provocative factors
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13
Q

High risk acute pericarditis

A
Fever
Large pericardial effusion
Tamponade
Immunocompromised
Hx of warfarin
Acute trauma
No improvement w/in 7 days of NSAID
Cardiac troponin
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14
Q

Acute pericarditis PE

A

Vitals - fever (bacterial)
Heart - pericardial rub LSB
Lungs - rub

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15
Q

Acute pericarditis diagnostics

A

ECG - diffuse ST elevation, PR segment depression, Concave upsloping ST
CXR
Echo
Lab - CBC, ESR/CRP, cardiac enzymes

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16
Q

Acute pericarditis tx post MI

A

ASA + Colchicine

No steroids or NSAIDS

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17
Q

Acute pericarditis tx viral/idiopathic

A

Rest
Colchicine + NSAIDS (motrin, indomethacin)
Steroids (refractory only)

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18
Q

Pericardial effusion

A

Amount of pericardial fluid exceeds normal

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19
Q

Majority of pericardial effusion results from?

A
Aortic dissection
Hypothyroidism
Mediastinal radiation
Post MI or cardiac surg
Renal failure w uremia
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20
Q

Clinically silent pericardial effusion?

A

Yes its a thing

Slow onset

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21
Q

Pericardial effusion clinical features

A
Dypsnea (lung compression)
Dysphagia (esophagus compression)
Hoarseness (laryngeal nerve compression)
Hiccups (phrenic nerve irritation)
JVP increase
Arterial pulse decrease pressure
Rub
Atypical chest pain
22
Q

Pericardial effusion ECG changes

A

Flat T
Low voltage

Id’s as little as 20ml extra

23
Q

Pericardiocentesis

A

Diagnostic as therapeutic

Send fluid to lab

24
Q

Pericardial effusion treatment

A

Mild (asymptomatic) - monitor
Moderate - drain (repeatedly)

  • last resort remove all or part of pericardial sac
25
Q

Cardiac tamponade raises inter-pericardial pressure, this leads to?

A
  1. Increased atrial pressure -> decreased Venus return
  2. Increased ventricular pressure -> decreased diastolic ventricular filling -> decreased cardiac output -> hypotension and venous congestion
26
Q

Becks triad

A

HOTN, JVD, Muffled heart tones

27
Q

Cardiac tamponade SS

A
Becks triad
Atypical chest pain
*Small quiet heart
Tachycardia
Loss of y descent in JVP
*Pulsus paradoxus 
Shock
Death
28
Q

Pathognomonic for cardiac tamponade

A

Electrical alternans

29
Q

ECG for cardiac tamponade

A

Electrical alternans

Heart is sloshing around

30
Q

Tamponade and inflammatory signs?

A

Acute idiopathic pericarditis

31
Q

Large effusion with NO inflammatory signs or tamponade

A

Chronic idiopathic pericardial effusion

32
Q

Tamponade w/out inflammatory signs

A

Malignant effusion

33
Q

Cardiac catheter

A

Definitive diagnostic procedure with pericardiocentesis for tamponade

34
Q

Exudate vs transudate lab results

A

Exudate: H Specific gravity, H protein, L glucose

Transudate: L specific gravity, L protein, H glucose

35
Q

Effusion and tamponade treatment

A

Treat underlying cause
Fluid management
Pericardiocenthesis

More aggressive tx in tamponade

36
Q

Cardiac tamponade vs constrictive pericarditis

A

Cardiac tamponade: pericardial fluid under pressure

Constrictive pericarditis: scarred, rigid pericardium

End result is the same

37
Q

constrictive pericarditis

A

A serious physiological state that developes as a consequence of chronic inflammatory changes to the pericardium

Fibrosis
Thickening
Adherence
Calcification

38
Q

Things that lead to constrictive pericarditis

A
Idiopathic/viral - 42-55%
Post cardiac surg - 11-37%
Post-radiation therapy (6-31%)
Post infectious (3-6%)
Misc (1-10%)
39
Q

What is the result of constrictive pericarditis?

A

Impairment of diastolic filling without impairment of systolic filling

40
Q

Whats the overall pathology of constrictive pericarditis?

A

Effusion leads to fusion of the pericardial layers resulting in scarring. This forms calcified layers which stiffens the pericardium

41
Q

What type of HF does constrictive pericarditis look like?

A

Mimics right sided heart failure

Pericardium doesnt allow RV to expand which backs up into RA which backs up systemically

42
Q

SS of constrictive pericarditis

A
Dyspnea
Fatigue
HOTN
Tachycardia
Abd pain
Cachexia
“Murmur” 
- precordial knock early diastolic just before S3
43
Q

Systemic symptoms of constrictive pericarditis or RHF in general

A
Insidious onset
elevated systemic pressures
Ascities
Hepatosplenomegaly
Peripheral edema
Increased JVP (93%)
Kussmaul’s sign
HOTN, tachycardia
44
Q

CXR for pericarditis

A

Pericardial calcifications

Minimal cardiac silhouette enlargement

45
Q

Constrictive pericarditis ECG changes

A

Non specific ST and T wave changes
Tachycardia is common
Low voltage
Atrial fibrillation

46
Q

Constrictive pericarditis TTE

A

Pericardial thickening
septal bounce (Intraventricular septum changes w respiration)
Early diastolic termination

47
Q

What test is essential for diagnosis for constrictive pericarditis?

A

TTE

48
Q

Constrictive pericarditis CMR (cardiac MRI)

A

Differentiates between pericardial thickening vs small effusions

Surgical candidates (pericardiectomy)

49
Q

Constrictive pericarditis CT scan

A

Pericardial anatomy, thickness and calcification

<2mm is normal

50
Q

Constrictive pericarditis cardiac catheterization

A

Confirmation test
Prominent y descent
Discordant RV/LV systolic pressures w inspiration

Differentiates between constrictive pericarditis and restrictive cardiomyopathy

51
Q

Constrictive pericarditis treatment

A

Pericardiectomy

20% mortality from surgery alone
Of those 90% do much better