CARDIO: MISC incl Cardiac tamponade, pericarditis, toxicity

Question 1

What is Cardiac Tamponade? Mechanism of how it happens?

Answer 1

Accumulation of fluid, blood, purulent exudate or air in the pericardial space.

This raises intra pericardial pressure.

Diastolic filling is reduced, which reduces cardiac output.

Life threatening emergency that requires prompt diagnosis with echocardiogram and treatment.

Question 2

How would a pt with cardiac tamponade present?

Answer 2

Shortness of breath
Tachycardia
Confusion
Chest pain
Abdominal pain

Question 3

What are the signs of cardiac tamponade. Hint a helpful ____ triad?

Answer 3

BECK’S Triad of signs:

1. Hypotension
2. Quiet heart sounds
3. Raised JVP

Other signs:
dyspnoea

pulsus paradoxus - an abnormally large drop in BP during inspiration.

an absent Y descent on the JVP - this is due to the limited right ventricular filling

Question 4

What are RF for cardiac tamponade?

Answer 4

malignancy,
purulent pericarditis,
severe thoracic trauma.

Question 5

What investigations for Cardiac tamponade?

Answer 5

ECG - low voltage QRS complexes or electrical alternans (alternating QRS amplitude)

Chest x-ray - show a large globular heart

ECHO - fluid around the heart and quantify the level of ventricular compromise.

Pericardiocentesis - sampling of the fluid to find the underlying cause and treat the immediate problem.

Question 6

What is first line management for cardiac tamponade in a haemodynamically unstable pt?

Answer 6

pericardiocentesis

using a needle and small catheter to drain excess fluid

Question 7

In a pt with cardiac tamponade when would surgical drainage be indicated as first line management ?

Answer 7

In patients with haemopericardium, associated malignancy, traumatic/purulent effusion

Question 8

What are some complications of pericardiocentesis?

Answer 8

pneumothorax (all patients should have a CXR post procedure to exclude this)

Damage to the myocardium / coronary vessels

Thrombus

Arrhythmias/cardiac arrest

Damage to the peritoneum.

Question 9

Causes of non-cardiac chest pain?

Answer 9

Costo-chondritis 
Gastro-oesophageal 
PE
Pneumonia 
Pneumothorax 
Psychogenic/psychosomatic

Question 10

What is top differencial for Cardiac tamponade?

Answer 10

Constrictive pericarditis

Question 11

How would differentiate between cardiac tamponade and constrictive pericarditis?

Answer 11

CT

• absent Y descent JVP - reduced RV filling
• Pulsus paradoxus - (+ drop in BP w/inspiration)

CP

• Y+ X present in JVP
• no Pulsus paradoxus
• Kussmaul’s sign +ve
• Pericardial calcification seen on CXR

Question 12

How does GTN spray help alleviate symptoms of angina

CVS revision

Answer 12

1) Nitric oxide causes vascular smooth muscle relaxation. NO activates granulate cyclase which increases cGMP. this lowers intracellular calcium levels so causes relaxation of vascular smooth muscle.
2) It acts primarily on veins - ventilation will lower preload. So the heart will fill less so force of contraction is reduced. This lowers oxygen demand needed.
3) GTN also acts on coronary collateral arteries - so improves oxygen delivery to the ischaemic heart muscle.

Question 13

ECG findings in PE?

Answer 13

Sinus tachycardia
“S1Q3T3” pattern of acute cor pulmonale is classic; this is termed the McGinn-White Sign.
—> A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain

Question 14

Symptoms of digoxin toxicity?

Answer 14

• abdo pain
• nausea
• vomitting
• arrythmia
• yellow-green tint to vision
• diarrhoea
• confusion
• fatigue
• palpitations

Question 15

RF for digoxin toxicity?

Answer 15

• hypokalaemia
• hypomagnesia
• hypercalcaemia
• elderly

Question 16

ECG changes in digoxin toxicity?

Answer 16

• Downsloping ST depression - ‘Reverse Tick’
• T wave changes (inversion)
• Biphasic/flattened and shortened QT interval
• Slight PR interval prolongation

Question 17

Treatment for digoxin toxicity?

Answer 17

Stop digoxin
Correct dyselectrolytaemia
Administer digifab (digoxin specific antibody indicated in lifethreatening digoxin toxicity).

Question 18

What is dresslers syndrome?

Answer 18

central, pleuritic chest pain and fever 4 weeks following a myocardial infarction. The ESR is elevated - Dressler’s syndrome

Question 19

What is acute pericarditis?

Answer 19

inflammation of the pericardial sac, lasting for less than 4-6 weeks.

Question 20

Causes of acute pericarditis?

Answer 20

• viral infections (Coxsackie)
• tuberculosis
• uraemia
• post-myocardial infarction
• early (1-3 days): fibrinous pericarditis
• late (weeks to months): autoimmune pericarditis (Dressler’s syndrome)
• radiotherapy
• connective tissue disease
• systemic lupus erythematosus
• rheumatoid arthritis
• hypothyroidism
• malignancy
  lung cancer
  breast cancer
• trauma

Question 21

Features of pericarditis?

Answer 21

• chest pain: may be pleuritic. Is often relieved by sitting forwards
• other symptoms include a non-productive cough, dyspnoea and flu-like symptoms
• pericardial rub: heard as a scratching or creaking noise at the left lower sternal border.

Question 22

Inv for acute pericarditis?

Answer 22

Bedside:
* ECG: widespread saddle shaped ST elevation, PR depression
Bloods:
* FBC- for WBCs
* CRP
* Troponins (may be elevated, this could be myocrditis)
Imaging:
* Transthoracic echocardiography

Question 23

Management of acute pericarditis?

Answer 23

• the majority of patients can be managed as outpatients
  patients who have high-risk features such as fever > 38°C or elevated troponin should be managed as an inpatient
• treat any underlying cause
  most patients however will have pericarditis secondary to viral infection, meaning no specific treatment is indicated
• strenuous physical activity should be avoided until symptom resolution and normalisation of inflammatory markers
• a combination of NSAIDs and colchicine is now generally used for first-line for patients with acute idiopathic or viral pericarditis
• until symptom resolution and normalisation of inflammatory markers (usually 1-2 weeks) followed by tapering of dose recommended over