JH IM Board Review - Pericardial Disease I

Question 1

What is the normal amount of pericardial fluid?

Answer 1

15-50mL.

Question 2

What is the definition of acute pericarditis?

Answer 2

Signs/symptoms of pericardial inflammation that are <1-2weeks in duration.

Question 3

What is the percentage of pts w/ nonischemic chest pain that have acute pericarditis?

Answer 3

5%.

Question 4

What is the percentage of pts w/ ST elevation on ECG that have acute pericarditis?

Answer 4

1%.

Question 5

What are the major categories of causes of acute pericarditis?

Answer 5

1. Idiopathic.
2. Infectious.
3. Neoplastic.
4. Autoimmune.
5. Uremia.
6. Cardiac surgery.
7. Irradiation.
8. Traumatic events.
9. Infarction.

Question 6

What are the 2 MCCs of acute pericarditis?

Answer 6

Viral or idiopathic.

Question 7

What percentage of pts w/ acute pericarditis will have an audible friction rub?

Answer 7

85%.

Question 8

What is the characteristic auscultatory finding in acute pericarditis?

Answer 8

High-pitched scratchy or squeaky sound best heard at the left sternal border at end-expiration w/ the pt leaning forward.

Question 9

What are the 3 main components of the high-pitched scratchy or squeaky sound of acute pericarditis?

Answer 9

They are related to movement of the heart during the cardiac cycle:

Atrial systole ==> Ventricular systole ==> Ventricular diastole.

Question 10

What are the 2 special syndromes of pericarditis?

Answer 10

1. Dressler.

2. Postpericardiotomy.

Question 11

What are the 4 stages of ECG in acute pericarditis?

Answer 11

Stage I ==> Diffuse ST elevation + PR depression in most leads (except aVR).

Stage II ==> Normalization of the ST segment and PR interval.

Stage III ==> Widespread T inversions.

Stage IV ==> Normalization of the T waves.

Question 12

What is the physical course of acute idiopathic or viral pericarditis?

Answer 12

Usually a benign, self-limited disease that typically resolves within 2 to 6 weeks.

Question 13

What is the treatment of acute pericarditis?

3

Answer 13

1. NSAIDs.
2. Colchicine.
3. Limitation of strenuous physical activity.

Question 14

What is the timeline of NSAIDs tx?

Answer 14

Can begin tapering after 1 to 2 weeks of tx if sx free.

Question 15

What is the timeline of colchicine tx?

Answer 15

0.6-1.2mg twice daily for 3months.

==> Usually well tolerated, reduces symptoms, and decreases rate of recurrent pericarditis.

Question 16

What is the evidence supporting limitation of strenuous physical activity for 2 to 6months in acute pericarditis?

Answer 16

There is none.

Question 17

What is the role of CS in acute pericarditis?

Answer 17

AVOID USING THEM — leads to higher rates of recurrent pericarditis, especially during weaning.

==> Can be necessary if refractory sx.

Question 18

What is important to keep in mind about the tx of post-MI pericarditis?

Answer 18

Avoid NSAIDs or CS.

Question 19

What is the role of anticoagulants in the tx of acute pericarditis?

Answer 19

They should be avoided.

Question 20

What are the hospitalization criteria for acute pericarditis?

(9)

Answer 20

1. Temp >38.
2. Subacute onset (sx over weeks).
3. Immunosuppression.
4. Trauma-induced.
5. Tx w/ oral anticoagulants.
6. Myopericarditis.
7. Imaging suggesting a large pericardial effusion (>20mm in width).
8. Signs of tamponade.
9. Concomitant MI.

Question 21

What is the percentage of pts w/ acute pericarditis that develop tamponade?

Answer 21

15%.

Question 22

What are the main effects of a pericardial effusion?

Answer 22

1. Limited diastolic filling.
2. Decreased SV + CO.
3. Elevated venous pressures.
4. Decreased BP.

Question 23

What is the Ewart sign?

Answer 23

Dullness to percussion and bronchial breath sounds beneath the left scapula caused by compressive atelectasis in the left lower lung field.

Question 24

What are the echo findings that support a dx of tamponade?

4

Answer 24

1. RA (late diastolic) + RV (early diastolic) collapse.
2. Exaggerated ventricular septal shift.
3. Marked respiratory variation in Doppler echo inflow velocities across MV and TV (flow velocity paradox) — also seen in constrictive pericarditis.
4. Enlargement of the IVC — correlates w/ increased jugular vein distention.

Question 25

What is the meaning of an exaggerated ventricular septal shift?

Answer 25

1. An increase in RV volume w/ inspiration shifts the septum toward the LV in diastole. 2. W/ expiration, a decrease in RV volume shifts the septum to the right. 3. This pattern of motion, while normal, is exaggerated in pts w/ tamponade, and leads to pulsus paradoxus.

Question 26

What is the effect of tamponade on intrapericardial pressures?

Answer 26

It increases them — leading to equalization of RA, diastolic RV, and PCWP.

Question 27

What is the tx of asx pericardial effusions?

Answer 27

Even large ones, may be followed indefinitely with serial echo and clinical assessments.

Question 28

What is the only indication of pericardiocentesis in a pericardial effusion?

Answer 28

Only needed if fluid sampling is required to establish a dx, especially if sx are suggestive of bacterial infection (ie purulent pericarditis).

Question 29

What is the method of pericardiocentesis?

Answer 29

A wide-bore needle is inserted into the epigastrium below the xiphoid process and advanced in the direction of the medial third of the right clavicle.

Question 30

What is the way by which we distinguish a bloody pericardial effusion from accidental puncture of the heart?

Answer 30

If the needle is connected to the V lead of an echo monitor, ST elevation is usually seen if the needle touches the EPICARDIUM.

Question 31

What are the 4 main complications of pericardiocentesis?

Answer 31

1. Accidental puncture of the heart. 2. Arrhythmias. 3. Vasovagal attack. 4. Pneumothorax.

Question 32

What are the 2 temporizing measures before pericardial fluid evacuation in tamponade?

Answer 32

1. Expansion of intravascular volume w/ fluids. | 2. Administration of vasopressors.

Question 33

What is that may be required for recurrent episodes of pericardial effusion and tamponade? (5)

Answer 33

1. Repeated pericardiocenteses. 2. Balloon pericardiotomy. 3. Surgical creation of a pericardial window. 4. Surgical pericardiectomy. 5. Injection of a sclerosing agent into pericardial space to cause adherence of the visceral and parietal pericardium.

Question 34

What is the pericardial knock seen in constrictive pericarditis?

Answer 34

Extra heart sound heard in early diastole (mimics an S3), coinciding w/ abrupt cessation in ventricular filling b/c of the rigid pericardium.

Question 35

What is the definitive tx for constrictive pericarditis?

Answer 35

Total pericardiectomy (surgical removal of the pericardium).