Pericardial Disease

Question 1

What are the 3 functions of the pericardium?

Answer 1

1. Fixes heart within the mediastinum, limiting its motion
2. Prevents extreme dilatation of the heart during sudden rises of cardiac volume
3. Barrier to spread of infection from adjacent structures

Question 2

3 causes of infectious acute pericarditis.

Answer 2

1. Viral (most common)
2. TB
3. pyogenic bacteria

Question 3

2 connective tissue conditions that can cause non-infectious acute pericarditis.

Answer 3

1. SLE

2. Rheumatoid Arthritis

Question 4

What causes both early and late pericarditis secondary to MI?

Answer 4

Early: inflammatory response to necrotic heart tissue

Late: autoimmune reaction to necrotic tissue

Question 5

Name the 7 drugs that can lead to acute pericarditis.

Answer 5

Lupus-like side effects

1. Procainamide (class 1A AA)
2. Hydralalzine (direct vasodilator)
3. Methyldopa (alpha-2 agonist)
4. Isoniazide (TB antibiotic)
5. Phenytoin (class 1B AA)

Misc.

6. Minoxidil (direct vasodilator)
7. Anthracycline (chemotherapy)

Question 6

Auscultatory hallmark of acute pericarditis.

Answer 6

Pericardial Friction Rub

-best heard on left sternal border when HR is less than 120

Question 7

How does acute pericarditis present in EKG?

Answer 7

At least one lead containing both ST elevation and PR depression

Question 8

Best treatment for acute viral pericarditis.

Answer 8

Rest
NSAIDs
(oral steroids or colchicine if NSAIDs don’t work)

Question 9

Best treatment for acute TB pericarditis

Answer 9

TB therapy

Question 10

Tx for purulent pericarditis.

Answer 10

Drainage and antibiotics

Question 11

Tx for uremic pericarditis

Answer 11

Dialysis

Question 12

Tx for pericarditis post MI.

Answer 12

ASA, avoid other NSAIDs and steroids

Question 13

Most useful test to diagnose pericardial effusion.

Answer 13

Echo

Question 14

A variety of symptoms can present with pericardial effusion. What is the reason for variety?

Answer 14

Rate of effusion determines the symptoms. Slow rates can be asymptomatic, fast rates can cause dyspnea, fatigue, or chest discomfort.

(volume and compliance can also affect symptoms)

Question 15

What is the Ewart Sign?

Answer 15

Maybe the only physical exam sign for pericardial effusion.

Dullness to percussion over the angle of the left scapula due to compression of the left lung by the enlarged pericardial sac

Question 16

What are 2 EKG signs that may be evident with pericardial effusion?

Answer 16

1. Low Voltage

2. Electrical Alternans (alternating large and small QRS complexes)

Question 17

How does pericardial effusion appear on CXR?

Answer 17

Water bottle appearance if large enough.

Question 18

Modality of choice to diagnose pericardial effusion.

Answer 18

Echo

Question 19

What is the treatment for pericardial effusion?

Answer 19

Treat underlying cause.

If cause is unknown or a pericardial tamponade, pericardiocentesis

Question 20

What is cardiac tamponade?

Answer 20

Cardiac chamber compression due to pericardial effusion.

Question 21

What is a normal pulsus paradoxus?

Answer 21

Drop in systolic blood pressure due to inspiration. Normal is approx 10mmHg.

Question 22

Why does cardiac tamponade cause a larger/exaggerated pulsus paradoxus?

Answer 22

Compression on the chambers causes an even further deviation of the IV septum into the left ventricle due to expansion of the RV during inhalation. This decreases SV increasing the pulsus paradoxus.

Question 23

How can cardiac tamponade lead to confusion or agitation?

Answer 23

Lower SV decreases perfusion to the brain.

Question 24

What are common physical findings with cardiac tamponade?

Answer 24

Beck Traid

1. Hypotension
2. JVD
3. Muffled Heart Sounds

Other signs:
exaggerated pulsus paradoxus (greater than 10mmHg), tachycardia, chest discomfort

Question 25

Test of choice for cardiac tamponade.

Answer 25

Echo

Question 26

What will cardiac catheterization show with cardiac tamponade?

Answer 26

All chambers will have equal pressure Right atrial tracing will have a blunted "y" descent due to impaired ventricular expansion and ability to receive blood from the atria.

Question 27

What is the definitive treatment for cardiac tamponade?

Answer 27

Pericardiocentesis -can also give IV fluids and (+)inotropic drugs to improve cardiac output

Question 28

Functionally, how does constrictive pericarditis differ from cardiac tamponade?

Answer 28

CT: ventricular filling is impaired all thru diastole CP: ventricular filling is only impaired in mid-late diastole because the restriction only occurs once the ventricles expand to a certain size

Question 29

What used to be the major cause for constrictive pericarditis?

Answer 29

TB | -he said it's a popular board question

Question 30

What is the best modality for diagnosis of constrictive pericarditis?

Answer 30

H+P

Question 31

What are common signs and symptoms of constrictive pericarditis?

Answer 31

Similar to R. sided heart failure - lower extremity edema - abdominal fullness, fatigue, dyspnea Signs: pericardial "knock", Kussmaul sign, JVD

Question 32

What is the pericardial "knock".

Answer 32

Heart sound that occurs with constrictive pericarditis. It is caused by the heart contacting the non-compliant pericardium during rapid filling of early diastole.

Question 33

What is the Kussmaul Sign?

Answer 33

Present in constrictive pericarditis. The rigid pericardium prevents the transmission of intrathoracic pressure to the right side of the heart. Results in: no abnormal pulsus paradoxus Jugulovenous pressure increases in inspiration (these two signs allow CP to be differentiated from tamponade)

Question 34

What is the treatment for Constrictive Pericarditis?

Answer 34

Pericardiectomy: removal of the pericardium Electrolyte restriction for symptoms.