Flashcards in Chapter 288 - Pericardial Disease Deck (57)
Name the functions of the normal pericardium.
"The normal pericardium, by exerting a restraining force, prevents sudden dilation of the cardiac chambers, especially the right atrium and ventricle, during exercise and with hypervolemia. It also restricts the anatomic position of the heart, and probably retards the spread of infections from the lungs and pleural cavities to the heart."
The partial absence of the pericardium might be related to sudden death.
True or False?
"In partial left pericardial defects, the main pulmonary artery and left atrium may bulge through the defect; very rarely, herniation and subsequent strangulation of the left atrium may cause sudden death."
The pain related to acute pericarditis has always pleuritic characteristics.
True or False?
"The pain of acute pericarditis is often severe, retrosternal, and left precordial, and referred to the neck, arms, or left shoulder. Frequenetly the pain is pleuritic, consequent to accompanying pleural inflammation (...) but sometimes it is steady, constricting, radiates into either arm or both arms, and resembles that of myocardial ischemia"
Name five examples of pericarditis in which there might not be any chest pain.
"Pain is often absent in slowly developing tuberculous, postirradiation, and neoplastic, uremic, and constrictive pericarditis."
Since acute pericarditis might be confounded with myocardial infarction and both might have elevation of serum biomarkers, how does one distinguish the pattern of elevation of these conditions?
"However, these elevations, if they occur, are quite modest given the extensive electrocardiographic ST-segment elevation in pericarditis. This dissociation is useful in differentiating between these conditions."
How frequent does one hear a pericardial friction rub at some point of the acute pericarditis?
What are the four principal diagnostic features of acute pericarditis?
Chest pain, pericardial friction rub, supra-ST on ECG and pericardial effusion.
The main ECG characteristic of acute pericarditis is the presence of widespread ST elevation. What leads might be recipocrally depressed?
aVR and sometimes V1
What is the pathophysiollogy of ST segment elevation and PR segment depression in acute pericarditis?
ST segment elevation is do due to envolvement of epicardial tissue whereas PR segment depression is due to atrial envolvement.
Explain the stages of ECG changes in acute pericarditis.
"In stage 1, there is widespread elevation of the ST segments (...) After several days, the ST segments return to normal (satage 2), and only then, or even later, do the T waves become inverted (stage 3). Weeks or months after the onset of acute pericarditis, the ECG returns to normal (stage 4)."
What are the main differences of an ECG due to acute pericarditis and acute myocardial infarction (AMI)?
" The electrocardiogram (ECG) in in acute pericarditis without massive effusion usually displays changes secondary to acute subepicardial inflammation (...) there is widespread elevation of the ST segments, often with upward concavity, involving two or three standard limb leads and V2 to V6, with reciprocal depressions only in aVR and sometimes V1."
"In contrast, in AMI, ST elevations are convex, and reciprocal depression is usually more proeminent; these changes may return to normal within a day or two. Q waves may develop, with loss of R-wave amplitude, and T-wave inversions are usually seen within hours before the ST segments have become isoelectric."
How do you define clinically a pericardial effusion? What is Ewart's sign?
"Pericardial effusion is usually associated with pain and/or the ECG changes mentioned above, as well as electrical alternans. Pericardial effusion is especially important clinically when it develops within a relatively short of time because it may lead to tamponade (...) heart sounds may be fainter with pericardial effusion. The base of the left lung may be copmpressed by pericardial fluid, producing Ewart's sign, a pacth of dullness and increased fremitus (and egophony) beneath the angle of the left scapula."
In echocardiography where does one look for small pericardial effusions?
"The presence of pericardial fluid is recorded by two-dimensional transthoracic echocardiography as a relatively echo-free space between the posterior pericardium and left ventricular epicardium in patients with small effusions"
Compare CT and MRI to echocardiography.
CT and MRI "may be superior to echocardiography in detecting loculated pericardial effusions, pericardial thickening, and the identification of pericardial masses."
Define Mulibrey nanism.
"An autosomal recessive syndrome characterized by growth failure, muscle hypotonia, hepatomegaly, ocular changes, enlarged cerebral ventricles, mental retardation, ventricular hypertrophy, and chronic constrictive pericarditis."
Which therapies might be responsible for decreasing and increasing the risk for recurrent acute pericarditis?
Colchicine and glucocorticoids, respectively.
Which therapies and respective dosages are useful in acute pericarditis?
Aspirin (2-4g/d) with gastric protection (omeprazole 20mg/d) or NSAIDs such as ibuprofen (400-600mg tid) or indomethacin (25-50mg tid) for 1-2 weeks
Colchicine (0,5mg bid) for 4-8 weeks
Glucocorticoids (prednisone 1mg/Kg per day)
Which group of drugs should be avoided in acute pericarditis?
"Anticoagulants should be avoided because their use could cause bleeding into the pericardial cavity and tamponade."
Which patients might be candidates for pericardial stripping?
"In patients with recurrences that are multiple, frequent, disabling, continue for more than 2 years, and are not prevent by colchicine and other NSAIDs and are not controlled by glucocorticoids, pericardial stripping may be necessary to terminate the illness, and usually does so."
What are the main causes of cardiac tamponade?
"The most common causes of tamponade are idiopathic pericarditis and pericarditis secondary to neoplastic disease. Tamponade may also result from bleeding into the pericardial space after leakage from an aortic dissection, cardiac operations, trauma, and treatment of pacients with acute pericarditis with anticoagulants."
What are the features of Beck's triad.
"hypotension, soft or absent heart sounds, and jugular venous distension with a proeminent x descent but an absent y descent."
Is there a cutoff volume that is responsible for cardiac tamponade?
No, the cardiac tamponade depends on the velocity at which the pericardial effusion develops. Therefore, "The quantity of fluid necessary to produce cardiac tamponade may be as small as 200 mL when the fluid develops rapiodly to as much as >2000mL in slowly developing effusions when the pericardium has had the opportunity to stretch and adapt to an increasing volume."
Explain the mechanism for paradoxical pulse.
"Because both ventricles share a tight incompressible covering, i.ex., the pericardial sac, the inspiratory enlargement of the right ventricle in cardiac tamponade compresses and reduces left ventricular volume; leftward bulging of the interventricular septum reduces further the left ventricular cavity as the right ventricle enalrges during inspiration. Thus, in cardiac tamponade, the normal inpisratory augmentation of right ventricular volume causes an exxagerated reduction of left ventricular volume, stroke volume, and systolic pressure."
How frequent is padoxical pulsus in constrictive pericarditis?
About one-third of the patients.
Name the conditions associated with paradoxical pulse.
Cardiac tamponade, constrictive pericarditis, acute and chronic obstructive pulmonary diseases, pulmonary embolism, hypovolemic/hemorrhagic shock and some cases of right ventricle myocardial infarcation.
What is the definition of low-pressure tamponade?
"Low-pressure tamponade refers to mild tamponade in which the intrapericardial pressure is increased from its slighly subatmospheric levels to +5 to +10 mmHg (...) the central venous pressure is normal or only slightly elevated, whereas arterial pressure is unaffected (...) The patiensta are asymptomatic or complain of mild weakness and dyspnea. The diagnosis is aided by echocardiography, and both hemodynamic and clinical manifestations improve after pericardiocentesis."
How do you expect to find flow velocities through the valves of the heart and pulmonic vein in cardiac tamponade?
"Doppler ultrasound shows that tricuspid and pulmonic valve flow velocities increase markedly during inspiration, whereas pulmonic vein, mitral, and aortic flow velocities diminish (as in constrictive pericarditis)"
How does one monitor a large pericardial effusion?
"Arterial and venous pressures should be monitored and serial echocardiograms obtained."
Surgical drainge through a limited (subxiphoid) thoracotomy may be required in recurrent tamponade, when it is necessary to remove loculated effusions, and/or when it is necessary to obtain tissue for diagnosis.
True or False?
Name the conditions associated with a bloody fluid drained from the pericardial cavity.
"Bloody fluid is most commonly due to neoplasm, renal failure, or dyalisis in the United States and tuberculosis in developing nations but may also be found in the effusions of acute rheymatic fever, after cardiac injury, and after myocardial infarction."
Which virus might be associated with acute pericarditis?
"Commonly (...) viral isolation and serologic studies are negative. In some cases, coxsackievirus A or B or the virus of inluenzae, echovirus, mumps, herpes simplex, chickenpox, adenovirus, or cytomelovirus has been isolated from pericardial fluid and/or appropriate elevations in viral antibody titers have been noted. Pericardial effusion is a common cardiac manifestation of HIV."
How does one explain a pericardial effusion in HIV positive patients?
"it is usually secondary to infection (often mycobacterial) or neoplasm, most often lymphoma."
What is the timing in establishing precordial discomfort and fever in acute pericarditis versus acute myocardial infarction (AMI)?
Fever and precordial pain develop almost simultaneously frequently 10-12 days after a presumed viral infection in acute pericarditis whereas chest pain precedes fever in AMI.
What is the most frequent complication for acute idiopathic pericarditis?
Recurrent (relapsing) pericarditis, which occurs in approximately one-fourth of the patients.
What is the mechanism for postcardiac injury syndrome resulting in acute pericarditis?
"This syndrome is probably the result of a hypersensitivity reaction to antigen(s) that originate from injured myocardial tissue and/or pericardium."
Which rheumatologic causes for acute pericarditis should be considered in the differential diagnosis of acute pericarditis?
"It is important to distinguish pericarditis due to collagen vascular disease from acute idiopathic pericarditis. Most important in the differential diagnosis is the pericarditis due to systemic lupus erythematous (SLE) or drug-induced (procainamide or hydralazine) lupus. When pericarditis occurs in the absence of any obvious underlying disorder, the diagnosis of SLE may be suggested by a rise in the titer of antinuclear antibodies. Acute pericarditis is an occasional complication of rheumatoid arthirtis, scleroderma, and polyarteritis nodosa, and other evidence of these diseases is usually obvious."
Pyogenic pericarditis might be due to rupture of a ring abcess in a patient with infective endocarditis.
True or False?
Pyogenic pericarditis usually has a poor prognosis.
True or False?
Drainage is mandatory in pyogenic pericarditis.
True or False?
How frequent is pericarditis in chronic uremia?
"Pericarditis of renal failure occurs in up to one-third of patients with chronic uremia (uremic pericarditis), and is also seen in patients undergoing chronic dialysis who have normal levels of blood urea and creatinine (dyalisis-associated pericarditis)."
What is the treatment for pericarditis of renal failure?
"Treatment with an NSAID and intensification of dialysis are usually adequate."
Which neoplastic conditions are more commonly associated with pericardial invasion and consequent pericarditis?
Carcinoma of the lung and breast, malignant melanoma, lymphoma and leukemia.
Name unusual causes of acute pericarditis.
"Unusual causes of acute pericarditis unclude syphilis, fungal infection (histoplasmosis, blastomycosis, aspergillosis, and candidiasis), and parasitic infestation (amebiasis, toxoplasmosis, echinococcosis, and trichinosis)."
What is the main treatment for myxedematous pericardial effusion?
Thyroid hormone replacement.
Name a frequent condition associated with chronic pericardial effusions and consequent chronic constrictive pericaditis.
Which neoplastic processes might be associated with chronic constrictive pericarditis?
Breast cancer, lung cancer and lymphoma.
How different and similar is the restriction of ventricular filling comparing chronic constrictive pericarditis and cardiac tamponade?
"Ventricular filling is unimpeded during early diastole but is reduced abruptly when the elastic limit of the pericardium is reached, whereas in cardiac tamponade, ventricular filling is impeded throughout diastole. In both conditions, ventricular end-diastolic and stroke volumes are reduced and the end-diastolic pressures in both ventricles and the mean pressures in the atria, pulmonary veins, and systemic veins are all elevated to similar levels (i.e., within 5mmHg of one another)."
Myocardial injury in chronic constrictive pericarditis might contribute to venous congestion.
True or False?
"However, in advanced cases, the fibrotic process may extend into the myocardium and cause myocardial scarring and atrophy, and venous congestion may then be due to the combined effects of the pericardial and myocardial lesions."
What is Broadbent's sign?
Systolic retraction of the apical pulse.
How many patients have atrial fibrilation associated with chronic constrictive pericarditis?
About 1/3 of the patients.
Pericardial calcification always occurs with constriction of the heart.
True or False?
Calcification might occur with and without constriction.
What is the most important sign to distinguish ascitis due to hepatic cirrhosis and chronic constrictive pericarditis?
Distended jugular veins.
How does one distinguish between chronic constrictive pericarditis and cor pulmonale?
"Like chronic constrictive pericarditis, cor pulmonale may be associated with severe systemic venous hypertension but little pulmonary congestion; the heart is usually not enlarged, and a paradoxical pulse may be present. However, in cor pulmonale, advanced parenchymal pulmonary disease is usually apparent and venous pressure falls during inspiration (i.e., Kussmaul's sign is negative)."
How does one distinguish between chronic constrictive pericarditis and tricuspid stenosis?
"Tricuspid stenosis may also simulate chronic constrictive pericarditis; congestive hepatomegaly, splenomegaly, ascites and venous distension may be equally proeminent. However, in tricuspid stenosis, a characteristic murmur and the murmur of accompanying mitral stenosis are usually present."
What is the mortality and risks associated with pericardial resection in chronic constrictive pericarditis?
"The risk of this operation depends on the extent of penetration of the myocardium by fibrotic and calcific process, the severity of myocardial atrophy, the extent of secondary impairment of hepatic and/or renal function, and the patient's general condition. Operative mortality is in the range of 5 to 10% even in experienced centers"
In subacute effusive-constrictive pericarditis, what pattern of venous jugular wave do you expect?
"The heart is generally enlarged, and a parodical pulse and a prominent x descent (without a prominent y descent) are present in the atrial and jugular venous pressure pulses. After pericardiocentesis, the physiologic findings may change from those of cardiac tamponade to those of pericardial constrction."