Pericardium

Question 1

acute or recurrent pericarditis

workup

Answer 1

look for autoimmune disease
SLE, Sjögren syndrome, rheumatoid arthritis, and scleroderma, systemic vasculitides, Behçet syndrome, sarcoidosis, and inflammatory bowel diseases.
ANA, TB if immunocompromised/endemic, hypothyroidism (relative brady, low voltage)

Question 2

recurrent pericarditis treatment

Answer 2

more common if not treated with colchicine initially

colchicine 0.6mg BID (6-12 months) + (NSAID/aspirin: 2-4 week taper when asymptomatic)

Question 3

pericarditis diagnosis

Answer 3

clinical, confirm with CRP/imaging
get CXR, ECG, echo
do not do virologic testing

Question 4

pericarditis ECG

Answer 4

PR depression

Question 5

steroids in pericarditis

Answer 5

for patients unable to take NSAID therapy or for those with specific indications (autoimmune disease, renal failure, pregnancy, concomitant anticoagulant therapy).

Question 6

constrictive vs restrictive physiology

Answer 6

simultaneous LV and RV tracings
square root sign (dip and plateau in diastole due to rapid filling which is abruptly halted in constriction)
ventricular interdependence: during inspiration, right atrial pressures decrease transiently, resulting in increased venous return and RV filling and decreased LV filling, which leads to bowing of the interventricular septum towards the LV. During expiration, the reverse occurs.

Question 7

restrictive physiology

Answer 7

ventricular concordance: simultaneous drop in both RV and LV filling during inspiration

Question 8

hemodynamic tracings
MS
MR
TR
tamponade

Answer 8

diastolic gradient between LA and LV
tall v waves on PCWP tracing
tall v waves on RA tracing
equalization of the diastolic pressures between all four cardiac chambers due to the elevated pericardial pressures.

Question 9

cardiac tamponade diagnosis

echo

Answer 9

clinical, Beck’s triad (hypotension, JVD, decreased heart sounds), pulsus paradoxus (>10), tachycardia on presentation
>30% variation in mitral inflow with respiration/>60% in tricuspid, and a dilated IVC, diastolic collapse of right chambers, diastolic blunting of hepatic vein forward flow,

persistent tachy: urgent pericardiocentesis
if decompensation: fluids, inotropes or vasopressor support

Question 10

effusive-constrictive pericarditis

Answer 10

Failure of the right atrial pressure to fall by 50% or to a level <10 mm Hg after pericardiocentesis
elevated intrapericardial pressure, PCWP

Question 11

constrictive pericarditis signs

echo

Answer 11

lower extremity edema, Kussmaul’s sign (jugular venous distension that increased with inspiration) , and a pericardial knock
annulus reversus: lateral mitral annular velocity less than the medial mitral annular velocity, prominent septal bounce, diastolic hepatic venous flow reversal increased with expiration, the E wave velocity across the mitral valve is very high (due to the high left atrial pressure), but the deceleration time is very short, the mitral inflow decrease with inspiration

Question 12

pericarditis ECG

Answer 12

classically diffuse ST elevations and/or P-R depressions, except in aVR, where the findings are reversed

Question 13

pericardial cyst treatment

Answer 13

do not intervene unless symptomatic

Question 14

recurrent malignant pericardial effusion tx

constrictive pericarditis tx

Answer 14

pericardial window

pericardiectomy

Question 15

most sensitive echo finding for tamponade

Answer 15

IVC plethora

Question 16

innocent flow murmur

Answer 16

I/VI systolic murmur at the left upper sternal border without radiation

Question 17

management of pericardial effusion
suspected infection/cancer
elevated inflammatory markers
known associated disease
>20 mm

Answer 17

drain
treat as pericarditis
treat disease
drain if >3 months
Otherwise, follow up

Question 18

McConnell’s sign

Answer 18

acute pulmonary embolism: abnormal right ventricular free wall contraction with sparing of the apex.