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

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Flashcards in CVPR 04-04-14 08-09am Pericardial Disease slides - Horwitz Deck (33):
1

Pericardium defn./structure

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.

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Four types of pericardial disease:

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)

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Acute Pericarditis – Causes

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

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Acute Pericarditis – Presentation

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

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Acute Pericarditis – Dx

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

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Acute Pericarditis on EKG

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

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Acute Pericarditis – Treatment

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

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Pericardial effusion – Causes

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

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Pericardial effusion – mechanism of pericardial tamponade

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

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Pericardial effusion – Symptoms

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

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Pericardial effusion – Dx

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)

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Pericardial effusion/tamponade vs. Dilated cardiomyopathy

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.

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Constrictive Pericarditits – Mechanism/Pathophysiology

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

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Constrictive Pericarditits –Presentation

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)

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Constrictive Pericarditits –Dx

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

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Constrictive Pericarditits –filling curve

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

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Constrictive Pericarditits –Treatment

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

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Pericardial pain – distinguishing features

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

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Pericardial pain vs. Acute coronary syndrome pain

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

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Pericardial pain vs. Acute Pulmonary Embolism pain

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

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Pericardial pain vs. Pneumonia pain

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

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Pericardial Tamponade vs. Congestive Heart Failure - features in common

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

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Pericardial Tamponade vs. Congestive Heart Failure - timing of impairment

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

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Pericardial Tamponade vs. Congestive Heart Failure - lung findings

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

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Pericardial Tamponade vs. Congestive Heart Failure – Pulse findings

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)

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

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

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Pericardial Tamponade vs. Congestive Heart Failure - Echocardiograms

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

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Pericardial Tamponade vs. Constrictive Pericarditis – features in common

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

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Pericardial Tamponade vs. Constrictive Pericarditis – on x-ray

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

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Pericardial Tamponade vs. Constrictive Pericarditis – Pulse findings

Pulsus paradoxus is present in tamponade & uncommon in constriction.

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Pericardial Tamponade vs. Constrictive Pericarditis – time to develop

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

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Pericardial Tamponade vs. Constrictive Pericarditis – systemic findings

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

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Pericardial Tamponade vs. Constrictive Pericarditis. - Echocardiogram

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

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