Pericardial Disease

Question 1

The heart has an outer layer that covers it called the pericardium. The pericardium covers the heart and the roots of the great vessels (aorta etc.). It has 2 layers, which are called what?

1 - endocardium
2 - visceral (also called serous layer)
3 - parietal
4 - myocardium

Answer 1

2 - visceral (also called serous layer)
- contact with myocardium

3 - parietal
- contact with fibrous pericardium

Question 2

The pericardial cavity is the space contained between the pericardium layers (visceral and parietal)?

1 - blood vessels that supply coronary blood vessels
2 - lymphatic fluid drained from the heart
3 - serous fluid
4 - air

Answer 2

3 - serous fluid

• acts as a cushion for the heart
• typically there is <50ml fluid

Question 3

In addition to providing a cushion for the heart, what is another key function of the pericardium?

1 - supply blood to coronary blood vessels
2 - drain lymphatic fluid from the heart
3 - anchor heart to mediastinum
4 - all of the above

Answer 3

3 - anchor heart to mediastinum
- ensures heart is not twisted, which would obstruct the great vessels

Question 4

What is the name of the layer that surrounds the parietal pericardium?

1 - mediastinum
2 - fibrous pericardium
3 - endocardium
4 - pericardium obstructor

Answer 4

2 - fibrous pericardium
- ensures heart cannot over stretch

Question 5

Pericardial disease is due to an inflammation of the pericardium. This can be caused by all of the following, EXCEPT which one?

1 - virus
2 - bacteria
3 - fungi/parasite
4 - metabolic disturbances
5 - autoimmune
6 - MI
7 - drugs
8 - idiopathic

Answer 5

6 - MI

Question 6

If the cause of pericarditis is due to a viral infection, which of the following is NOT a common cause?

1 - coxsackie vurys
2 - herpes virus
3 - adenoviruses
4 - aspergillus

Answer 6

4 - aspergillus
- this is a fungal cause

Question 7

Procalcitonin is a biomarker present in the blood. If this is high, does it indicate inflammation/viral infection or a bacterial infection?

Answer 7

• bacterial infection

Question 8

Pericardial disease is due to an inflammation of the pericardium. Patients with acute pericarditis can present acutely. They can present with chest pain where?

1 - severe retrosternal chest pain
2 - neck
3 - shoulders and back
4 - painful on each breath
5 - all of the above

Answer 8

5 - all of the above
- painful on each breath as the pericardium is compressed as the lungs expand

Question 9

Pericardial disease is due to an inflammation of the pericardium. Patients with acute pericarditis can present acutely. They can present with severe retrosternal chest pain that radiates to the neck, shoulders and back. It is worse with each breath as the expanding lungs compress the pericardium. Is the pain lessened when the patient is supine and lying or sitting and leaning forwards?

Answer 9

• sitting and leaning forwards
• reduces pressure on the pericardium

Question 10

If a patient has pericarditis due to a viral infection, which of the following symptoms may they present with?

1 - fever and malaise
2 - myalgia
3 - arthralgia
4 - URTI symptoms
5 - pericardial rub
6 - all of the above

Answer 10

5 - all of the above

Question 11

If a patient has pericarditis, which of the following could be present on an ECG?

1 - ST elevation
2 - PR depression
3 - tachycardia
4 - all of the above

Answer 11

4 - all of the above

• 60% of patients have concave upward ST elevation in most, if not all leads, almost saddle shaped
• PR depression is more specific

Question 12

When trying to diagnose a patient with pericarditis, we can perform a full blood workup. Which 4 of the following are likely to be raised in myocarditis?

1 - troponin
2 - CRP
3 - Na+
4 - BNP
5 - ESR
6 - WBC
7 - D-dimer

Answer 12

1 - troponin
2 - CRP
5 - ESR
6 - WBC

Question 13

When trying to diagnose a patient with pericarditis, we can perform a chest X-ray and/or echocardiogram. What may we see?

1 - pericardial effusion
2 - tracheal deviation
3 - cardiomegaly
4 - hyper-inflated lungs

Answer 13

1 - pericardial effusion
- looks like a water bottle

• typically there is <50ml fluid

Question 14

When treating a patient with pericarditis which of the following medications should be used in the 1st 1-2 weeks?

1 - NSAIDs
2 - anti-emetics
3 - aspirin
4 - all of the above

Answer 14

4 - all of the above
- relieves pain and hopefully the cause will settle on its own

Question 15

When treating a patient with pericarditis, they are often given NSAIDs and/or aspirin with anti-emetics to protect the stomach for 1-2 weeks. If the pericarditis is not relieving, what should be added for a period of 3 months to reduce the risk of re-occurrence?

1 - vancomycin
2 - colchicine
3 - IL-1 antagonists
4 - steroids

Answer 15

2 - colchicine
- anti-inflammatory properties and inhibits neutrophil motility
- steroids, IL-1 antagonists and other medications may be used by a specialist only

Question 16

Fluid can collect in the pericardial space surrounding the heart and can fill between 500-1L of fluid. Which of the following are causes of a pericardial effusion?

1 - pericarditis
2 - myocardial rupture
3 - aortic dissection
4 - malignancy
5 - pericardium filling with pus
6 - all of the above

Answer 16

6 - all of the above

Question 17

In a patient with a pericardial effusion, they can be asymptomatic, but they can also present with all of the following EXCEPT which one?

1 - dyspnoea
2 - fatigue
3 - nausea (diaphragm)
4 - dysphagia (oesophagus)
5 - hoarse voice (recurrent laryngeal nerve)
6 - heart murmur
7 - hiccoughs (phrenic nerve)

Answer 17

6 - heart murmur
- not a common symptom

Question 18

When trying to diagnose a patient with a pericardial effusion, we can perform a chest X-ray and/or echocardiogram. What may we see?

1 - globular cardiomegaly
2 - tracheal deviation
3 - cardiomegaly
4 - hyper-inflated lungs

Answer 18

1 - globular cardiomegaly
- heart is not getting bigger here

Question 19

If a patient has pericarditis, which 2 of the following could be present on an ECG?

1 - ST elevation
2 - PR depression
3 - sinus tachycardia
4 - small complexes (QRS height may fluctuate)

Answer 19

3 - sinus tachycardia
4 - small complexes

• ECG leads are further away so lower voltage

Question 20

If the patient is haemodynamically stable, would a drainage of the pericardium be performed?

Answer 20

• typically no
• pericardiocentesis may be performed to diagnose though

Question 21

When would a drainage of the pericardial effusion be performed?

1 - if recurrent effusions occur
2 - if effusion if virally infected
3 - if cardiogenic shock occurs
4 - all of the above

Answer 21

3 - if cardiogenic shock occurs

Question 22

What is the main distinction between a pericardial effusion and cardiac tamponade?

1 - lower fluid levels restricting heart
2 - increased fluid restricting hearts ability to contract
3 - poor perfusion of coronary blood vessels
4 - increased CO2 build up

Answer 22

2 - increased fluid restricting hearts ability to contract
- tamponade is french for to plug up and smash
- lots of fluid means heart cannot contract properly

Question 23

If the fluid in the pericardial space continues to build up, can the fibrous layer expand to help with heart contractions?

Answer 23

• no
• relatively fixed so fluid is trapped, limiting how the heart can expand in size

Question 24

In cardiac tamponade what can happen to the heart chambers?

1 - RA and RV dilate
2 - LV and LA hypertrophy
3 - RA and RV diastolic collapse
4 - all of the above

Answer 24

3 - RA and RV diastolic collapse
- reduces ventricle filling

Question 25

In cardiac tamponade, we have something called Becks triad. Which of the following is NOT part of this triad? 1 - hypotension 2 - raised JVP 3 - collapsing pulse 4 - muffled heart sounds

Answer 25

3 - collapsing pulse - hypotension = reduced cardiac output - raised JVP = blood backing up - muffled heart sounds = fluid makes it harder to hear the heart sounds

Question 26

In addition to Becks triad, which other clinical signs from those here might we see? 1 - tachycardia 2 - kussmauls sign (increased JVP on inspiration) 3 - increased pulse 4 - all of the above

Answer 26

4 - all of the above

Question 27

When trying to diagnose a patient with a cardiac tamponade, we can perform an echocardiogram. What may we see? 1 - echo free zone around the heart 2 - increased resonance around the heart 3 - thickened myocardium 4 - ventricular regurgitation

Answer 27

1 - echo free zone around the heart

Question 28

If a patient has cardiac tamponade, is a drainage important?

Answer 28

- yes - can cause cardiogenic shock and death

Question 29

All of the following are locations used when performing a pericardial drainage in a patient with cardiac tamponade, EXCEPT which one? 1 - right of the xiphoid process 2 - under the costal margin 3 - aim for the right mid clavicle 4 - aim of the left mid clavicle

Answer 29

3 - aim for the right mid clavicle

Question 30

Constrictive pericarditis is a stiff pericardium that limits the ability of the heart to contract. Is this an acute or chronic process?

Answer 30

- chronic - pericardium becomes thick and scarred

Question 31

Which of the following is NOT a typical cause of constructive pericarditis? 1 - idiopathic 2 - TB 3 - viral infection 4 - recurrent pericarditis 5 - post cardiac surgery complication

Answer 31

3 - viral infection

Question 32

Constructive pericarditis is often referred to as heart in a box. What is the main aspect of the heart that is affected? 1 - systolic function 2 - diastolic function 3 - electrical conduction 4 - all of the above

Answer 32

2 - diastolic function - heart cannot stretch and fill enough - can be heard as a pericardial knock during diastole

Question 33

All of the following are signs of congestive pericarditis, EXCEPT which one? 1 - raised JVP 2 - kussmauls sign (raised JVP on inspiration) 3 - barrel chested 4 - quiet heart sounds 5 - hepatomegaly and ascites 6 - oedema

Answer 33

3 - barrel chested - common in COPD

Question 34

In congestive pericarditis is the pressures within the chambers of heart affected?

Answer 34

- yes chambers all have an equal pressure

Question 35

Which imaging modality can be used to differentiate between a pericardial effusion and pericardial thickening? 1 - MRI 2 - ultrasound 3 - echocardiogram 4 - chest X-ray

Answer 35

1 - MRI

Question 36

Constrictive pericarditis is a permanent condition, which typically progresses. Which 2 medications are typically given to manage the patient medically? 1 - furosemide 2 - bisoprolol 3 - ramipril 4 - atenolol

Answer 36

1 - furosemide - reduces oedema 2 - bisoprolol - reduce tachycardia - increase diastolic duration and filling

Question 37

In patients with severe constrictive pericarditis, they can have surgery called pericardiectomy (pericardial stripping) where the pericardium is remove to allow the heart to function properly. What is the mortality of this surgery? 1 - 1.2% 2 - 12% 3 - 24% 4 - 50%

Answer 37

2 - 12% - higher mortality in patients who are symptomatic as well