CVPR 04-04-14 08-09am Pericardial Disease slides - Horwitz

Question 1

Pericardium defn./structure

Answer 1

A fibroelastic sac w/visceral & parietal layers….. The visceral layer dirtectly abuts the epicardium (outer portion of the myocardium) and is contiguous w/the pleura around the lungs…..A very small quantity of fluid is normally present between the two layers (in the pericardial space); However, in certain diseases, large quantities of fluid may accumulate there.

Question 2

Four types of pericardial disease:

Answer 2

1. Acute Pericarditis …. 2. Pericardial Effusion w/out hemodynamic compromise …. 3. Cardiac tamponade (excessive pericardial fluid compresses heart & reduces CO = acute emergency)…. 4. Constrictive Pericarditis (chronic process where pericardium thickens until it compresses the heart & limits CO)

Question 3

Acute Pericarditis – Causes

Answer 3

Viral illness, CT/autoimmune disease, Uremia, Metastatic tumors

Question 4

Acute Pericarditis – Presentation

Answer 4

Chest pain of sudden onset, often severe & sharp, varying w/position & breathing

Question 5

Acute Pericarditis – Dx

Answer 5

Chest pain varies w/position & breathing…. Pericardial rub on cardiac exam (crackling/rubbing that sounds like it’s right up in your ears) that appear & disappear… EKG: Diffuse ST elevation…. ECHO: Pericardial fluid…. Response to anti-inflammatory agents

Question 6

Acute Pericarditis on EKG

Answer 6

ST segment is elevated (= injury) involving most of the heart (diffuse)

Question 7

Acute Pericarditis – Treatment

Answer 7

NSAID of choices: Ibuprofen….. other NSAIDs…. Aspirin….. Colchicine

Question 8

Pericardial effusion – Causes

Answer 8

Viral or acute idiopathic pericarditis, Metastatic malignancy, Uremia, Autoimmune disease, HypOthyroidism

Question 9

Pericardial effusion – mechanism of pericardial tamponade

Answer 9

While small pericardial effusions may be asymptomatic, moderate to large effusions cause high intrapericardial pressure —> compression & impaired filling of the right heart —> decreased right ventricular output [lungs are NOT congested] —> Inspiration decreases pressure, allowing increased RV filling, but since it can’t expand in the free wall, it impinges on the LV —> decreased stoke volume, paradoxical pulse, fall in systolic pressure during inspiration, ACUTE EMERGENCY

Question 10

Pericardial effusion – Symptoms

Answer 10

Asymptomatic w/small effusion & minimal intrapericardial pressure…. Cardiac tamponade w/ large effusion & high intrapericardial pressure = decrease SV, paradoxical pulse w/fall in systolic pressure >10mmHg during inspiration (EMERGENCY)….. NO wet lung symptoms

Question 11

Pericardial effusion – Dx

Answer 11

Best diagnosed by X-ray or esp. Echocardiogram; Also ECG findings…. X-ray = Enlarged heart W/OUT congested lung field…. ECHO: Collapse of Rt. Atrium and Rt. Ventricle in end-diastole + Dilation of inferior vena cava w/out the normal >50% reduction during inspiration (intrapericardial & venous pressures are very high)….. ECG: Nonspecific = Low voltage w/sinus tachycardia + Electrical alternans reflecting movement of heart back & forth w/in sea of fluid w/each beat (seen as decreased QRS every other beat)

Question 12

Pericardial effusion/tamponade vs. Dilated cardiomyopathy

Answer 12

Pericardial effusion/tamponade presents with enlarged heart and UN-CONGESTED lungs (b/c of decreased RV output as a result of pressure)….. Dilated cardiomyopathy presents with a dilated heart associated w/pulmonary venous congestion, edema, etc.

Question 13

Constrictive Pericarditits – Mechanism/Pathophysiology

Answer 13

Cardiac surgery, Radiation, Infection —> SCARRING & LOSS of ELASTICITY of the pericardium (usually takes time to develop, even years) —> Impaired diastolic filling w/normal systolic function

Question 14

Constrictive Pericarditits –Presentation

Answer 14

MARKEDLY elevated JVP (some of the highest you’ll see)….. ALWAYS Tachycardia….. often Hepatomegaly, Edema, Ascites (from hig venous pressure; often misdiagnosed as liver disease)….. Lungs NOT congested b/c constriction selectively impairs filling of RV (low output)

Question 15

Constrictive Pericarditits –Dx

Answer 15

Echocardiogram or X-ray ….. Normally-size cardiac silhouette encased by thickened (or calcified) pericardium; Lungs NOT congested (selective RV filling impairment)….. MRI/CT also see pericardial thickening

Question 16

Constrictive Pericarditits –filling curve

Answer 16

Filling occurs very abruptly in early diastole, w/little or no further filling later in diastole, unlike in normal filling curves (“Dip & Plateau” or “square root sign”)….. Also, the diastolic filling pressures are very high & equalized between Rt. & Lt. ventricles, whereas normally, diastolc RV pressure is much lower than diastolic LV pressure

Question 17

Constrictive Pericarditits –Treatment

Answer 17

Surgical stripping of the pericardium (hard procedure, but completely cures)

Question 18

Pericardial pain – distinguishing features

Answer 18

Pericardial pain is (1) “pleuritic” (aggravated by deep breathing) & (2) “positional” (relieved by sitting up or other postural changes)

Question 19

Pericardial pain vs. Acute coronary syndrome pain

Answer 19

Pain from acute coronary syndromes is not altered by breathing, cough or positional changes, as pericardial pain is

Question 20

Pericardial pain vs. Acute Pulmonary Embolism pain

Answer 20

Both may be pleuritic (aggravated by deep breathing/cough)…..BUT, Acute PE lacks ECG changes of pericarditis, lacks a pericardial rub, and often occurs in conjunction w/recent surgery or after long automobile/plane travel in which DVT (often w/localized tenderness) occurs in the lower extremities

Question 21

Pericardial pain vs. Pneumonia pain

Answer 21

Both may be pleuritic (aggravated by deep breathing/cough)…..BUT, pneumonia often has localized rales in the lung fields & sputum production

Question 22

Pericardial Tamponade vs. Congestive Heart Failure - features in common

Answer 22

Both may have Distended neck veins, Tachycardia, HypOtension, Large cardiac silhouette on xray

Question 23

Pericardial Tamponade vs. Congestive Heart Failure - timing of impairment

Answer 23

Tamponade = major impairment is in right heart filling during diastole ….. CHF = usually no impairment in right heart filling

Question 24

Pericardial Tamponade vs. Congestive Heart Failure - lung findings

Answer 24

Tamponade = NO lung congestion ….. CHF = diminished myocardial function causes congestion systemically and in lungs (rales, redistribution of blood flow to upper lobes)

Question 25

Pericardial Tamponade vs. Congestive Heart Failure – Pulse findings

Answer 25

Pulsus paradoxus & Low voltage/Pulsus alternans common in tamponade & rare in CHF….. Pulsus paradoxus = decrease >10mmHg in systolic pressure/amplitude during inspiration ….. Pulsus alternans = alternating strong & weak beats (LV systolic impairment)

Question 26

Pericardial Tamponade vs. Congestive Heart Failure – auscultation/palpation of the heart

Answer 26

Tamponade = heart sounds tend to be distant, apex may not be palpable….. CHF = more common to have normal heart sounds often w/murmurs & an S3, as well as the presence of ventricular lifts

Question 27

Pericardial Tamponade vs. Congestive Heart Failure - Echocardiograms

Answer 27

Tamponade = large pericardial effusion, right atrial collapse, lack of normal decrease in inferior vena cava diameter ….. CHF = poor contractile function, dilation of the ventricles w/out the distinctive tamponade findings

Question 28

Pericardial Tamponade vs. Constrictive Pericarditis – features in common

Answer 28

Reduced diastolic function w/ preserved systolic function. ….. JVD…. Tachycardia…. Tendency to hypotension

Question 29

Pericardial Tamponade vs. Constrictive Pericarditis – on x-ray

Answer 29

Tamponade = large cardiac silhouette on xray….. Constrictive pericarditis = silhouette is often normal & may have pericardial thickening/calcification

Question 30

Pericardial Tamponade vs. Constrictive Pericarditis – Pulse findings

Answer 30

Pulsus paradoxus is present in tamponade & uncommon in constriction.

Question 31

Pericardial Tamponade vs. Constrictive Pericarditis – time to develop

Answer 31

Tamponade = tends to develop more quickly….. Constrictive pericarditis = typically develops very slowly over considerable time

Question 32

Pericardial Tamponade vs. Constrictive Pericarditis – systemic findings

Answer 32

Constrictive pericarditis = often accompanied by hepatic congestion, ascites & marked pedal edema ….. these findings are uncommon in tamponade which tends to develop more quickly.

Question 33

Pericardial Tamponade vs. Constrictive Pericarditis. - Echocardiogram

Answer 33

Tamponade = Pericardial fluid, Right atrial collapse w/inspiration ….. absent in Constrictive pericarditis