Pericardial Disease Flashcards Preview

Cardiology > Pericardial Disease > Flashcards

Flashcards in Pericardial Disease Deck (20):
1

Anatomy of the Pericardium

  • Pericardium
  • Visceral pericardium (epicardium)
  • Parietal pericardium
  • Pericardial fluid
  • Ventricle stiffness determination

  • Pericardium
    • Sac that surrounds the heart & proximal portion of great vessels
  • Visceral pericardium (epicardium)
    • Single-celled layer of mesothelial cells closely adherent to the surface of the heart
    • Reflects onto the surface of outer fibrous pericardium
  • Parietal pericardium
    • Outer layer of the sac
    • Fibrocollagenous layer whose inner lining is also lined by mesothelial cells reflected from epicardium
  • Pericardial fluid
    • Small volume of fluid in the potential space in b/n the two layers of mesothelial cells
  • Ventricle stiffness determination
    • Myocardium (mostly)
    • Endocardium & pericardium (negligibly)

2

Pulmonary Venous Pressure

  • Pulmonary venous pressure
  • What increases LV stiffness
  • Effects of increased LV stiffness on pulmonary venous pressure

  • Pulmonary venous pressure
    • Generated by the RV
    • Fills the LV
    • Normal pressure = 10 mmHg
  • What increases LV stiffness
    • Endocardial thickening
      • Ex. fibroelastosis of the endocardium
    • Myocardial thickening
      • Ex. concentric hypertrophy
    • Pericardial thickening
      • Ex. fibrous thickening or pericardial fluid
  • Effects of increased LV stiffness on pulmonary venous pressure
    • Increased LV stiffness
    • --> higher pulmonary venous pressure to fill the LV to a normal volume
    • --> pulmonary venous hypertension 
      • --> pulmonary congestion
      • --> shortness of breath

3

Systemic Venous Pressure

  • Systemic venous pressure
  • What increases RV stiffness
  • Effects of increased RV stiffness on pulmonary venous pressure

  • Pulmonary venous pressure
    • Generated by venous tone & blood volume
    • Fills the RV
    • Normal pressure = 5 mmHg
  • What increases RV stiffness
    • Endocardial thickening
      • Ex. fibroelastosis of the endocardium
    • Myocardial thickening
      • Ex. concentric hypertrophy
    • Pericardial thickening
      • Ex. fibrous thickening or pericardial fluid
  • Effects of increased RV stiffness on pulmonary venous pressure
    • Sodium & water retention
    • --> higher systemic venous pressure to fill the RV
    • --> systemic venous hypertension
      • --> systemic congestion
        • --> elevated jugular venous pressure
        • --> enlarged liver
        • --> edema of the feet & ascites

4

Low Cardiac Output

  • What causes low cardiac output
  • Symptoms of chronic low cardiac output
  • Symptoms of acute low cardiac output

  • What causes low cardiac output
    • Compensatory rise in venous pressure isn't adequate to maintain stroke volume & cardiac ouptut
  • Symptoms of chronic low cardiac output
    • Fatigue
  • Symptoms of acute low cardiac output
    • Hypotension
    • Low pulse pressure
    • Thready pulse
    • Tachycardia
    • Sweaty, cold, & clammy hands
    • Confusion due to cerebral hypoperfusion
    • Renal insufficiency
    • Shock liver: cardiogenic shock-death

5

Pulmonary vs. Systemic Venous Pressure

  • LV vs. RV stiffness in a normal heart
  • Filling pressure in the LV vs. RV
  • Effects of a stiffer pericardial sac, fluid filled pericardium, or fibrotic thickened pericardium

  • LV vs. RV stiffness in a normal heart
    • Different & independent of each other
  • Filling pressure in the LV vs. RV
    • Stiffer LV is filled w/ higher pulmonary venous pressure (10 mmHg)
    • Thinner RV is filled w/ lower systemic venous pressure (5 mmHg)
  • Effects of a stiffer pericardial sac, fluid filled pericardium, or fibrotic thickened pericardium
    • Both ventricles will be equally stiff
    • Both ventricles must be filled by elevated & equal pulmonary & systemic venous pressures

6

Acute Pericarditis: Etiologies

  • Infective
  • Non-infective

  • Infective
    • Viral (coxsackie, HIV)
    • Bacterial (pyogenic bacteria, tuberculosis, etc.)
    • Fungal (candida)
  • Non-infective
    • Connective tissue diseases
    • Postmyocardial infarction (Dressler's)
    • Postcardiotomy syndrome
    • Renal failure (uremia)
    • Neoplastic diseases (lung, breast, lymphoma)
    • Radiation induced
    • Drug induced (procainamide, hydralazine)
    • Traumatic (instrumentation, accident)
    • Idiopathic

7

Acute Pericarditis: Pathogenesis & Pathology

  • Pathogenesis
  • Pathology

  • Pathogenesis
    • Vasodilation (transudation of fluid)
    • Increased vascular permeability (leakage of protein)
    • Leukocyte exudation (neutrophils & mononuclear cells)
  • Pathology
    • Serous
    • Fibrinous
    • Hemorrhagic
    • Suppurative
    • Chylous

8

Acute Pericarditis: Clinical Features, Diagnostic Tests, & Treatment

  • Clinical features
  • Diagnostic tests
  • Treatment

  • Clinical features
    • Pain: worsened by inspiration & lying down, relieved by sitting up & leaning forward
    • Dyspnea: common due to shallow breathing limited by pain
    • Fever
    • Rub: superficial, scratchy, to & fro
    • ECG changes: ST elevation w/ upwards concavity, PR depression
  • Diagnostic tests
    • Echo: presence of fluid supports, absence doesn't negate
    • PPD, RF, ANA
    • Search for malignancy
    • Pericardiocentesis: low diagnostic yield, reserved for large effusions w/ tamponade
  • Treatment
    • Pain relief: aspirin, NSAIDs
    • Recurring pericarditis: steroids
    • Purulent pericarditis: antibiotics, drainage
    • Tuberculosis: multidrug antituberculous therapy
    • Neoplastic: radiation, chemotherapy

9

Symptoms of Large Effusions

  • Due to compression of adjoining structures
  • Dysphagia
  • Hoarseness (recurrent laryngeal nerve compression)
  • Hiccups
  • Dyspnea
  • Ewart's sign
    • Compression of lung --> area of consolidation in teh left ifnrascapular region --> atalectasis --> percussion dullness & bronchial breathing
  • Muffled heart sounds
  • Reduced intensity of rub

10

Pericardial Effusion: Pathophysiology

  • Pericardial fluid
  • --> increased ventricle stiffness
  • --> increased rapidity & quantity of accumulation
    • Sudden increase of small amount of fluid
    • Slow accumulation of large amount of fluid
  • --> high venous pressures
  • --> distended atria & ventricles
  • --> distended fluid filled pericardium
  • --> equal pericardial & venous pressure
  • ► pericardial effusion w/ tamponade --> elevated venous (atrial & ventricular diastolic) pressures --> equal venous & pericardial pressures

11

Pericardial Effusion: Hemodynamics

  • Systemic & pulmonary venous pressures
  • RV diastolic pressure
  • RV pressure tracing
  • RA pressure tracing

  • Systemic & pulmonary venous pressures
    • aka LV & RV diastolic and LA & RA pressures
    • Elevated & equal
  • RV diastolic pressure
    • Elevated to > 1/3 of RV systolic pressure
  • RV pressure tracing
    • Early diastolic dip
  • RA pressure tracing
    • Absent "Y" descent

12

Pulsus Paradoxus

  • Definition
  • Paradox
  • Mechanism
    • Inspiration
    • Expiration
    • Pulsus paradoxus
  • Conditions that increase pulsus paradoxus

  • Definition
    • Inspiratory fall in arterial systolic pressure > 10 mmHg
    • Qualitatively the same
    • Quantitative exaggeration of the normal
  • Paradox
    • The pulse in all arteries (in the presence of regular & continuing heart motion) becomes very small or disappears entirely in regular intervals (inspiration) & returns immediately (expiration)
    • Paradox: discrepancy b/n heart action & arterial pulse
  • Mechanism
    • Inspiration
      • Decreased intrathoracic pressure
      • --> pulmonary venous pressure < extrathoracic systemic venous pressure
      • --> LV filling < RV filling
      • --> decreased arterial systolic pressure
      • --> decreased LV SV
    • Expiration
      • Increased intrathoracic pressure
      • --> pulmonary venous pressure > extrathoracic systemic venous pressure
      • --> LV filling > RV filling
      • --> increased arterial systolic pressure
      • --> increased LV SV
    • Pulsus paradoxus
      • Difference of > 10 mmHG b/n high expiratory & low inspiratory systolic pressure
      • Severe tamponade: difference > 20 mmHg
  • Conditions that increase pulsus paradoxus
    • Tamponade
    • Exaggerated respiratory inspiratory effort (stridor)
    • Exaggerated expiratory effort (asthma, COPD)

13

Cardiac Tamponade

  • Venous pressure
  • Pulsus paradoxus
  • Signs of low cardiac output
  • Echo
  • EKG
  • CXR

  • Venous pressure
    • Elevated
    • Kussmaul sign: inspiratory increae in venous pressure isn't present
  • Pulsus paradoxus
    • Present
    • Inspiratory fall in arterial systolic pressure > 10 mmHg
  • Signs of low cardiac output
    • Low arterial systolic & pulse pressure
    • Other signs of shock
  • Echo
    • Large effusion
    • Absence of inspiratory collapse of IVC
    • RA & RV collapse
    • Inspiratory decrease in mitral valve flow velocity > 25%
  • EKG
    • Low amplitude
    • Electrical alternans
  • CXR
    • Enlarged heart shadow (water bottle heart)

14

Cardiac Tamponade: Hemodynamics

  • Systemic & pulmonary venous pressures
  • RV diastolic pressure
  • RV pressure tracing
  • RA pressure tracing

  • Systemic & pulmonary venous pressures
    • aka LV & RV diastolic and LA & RA pressures
    • Elevated & equal
  • RV diastolic pressure
    • Elevated to > 1/3 of RV systolic pressure
  • RV pressure tracing
    • Early diastolic dip
  • RA pressure tracing
    • Absent "Y" descent

15

Cardiac Temponade: Treatment

  • Administer
  • Don't administer

  • Administer
    • Pericardiocentesis
    • Pericardial window
    • Balloon pericardiotomy
    • Surgical removal of part or all of the pericardium
    • IV fluids
    • Isoproterenol
  • Don't administer
    • Drugs that cause volume depletion (diuretics)
    • Drugs that cause bradycardia (beta blockers)
    • Negative inotropes (Ca2+ channel blockers)
    • Vasoconstrictors

16

Constrictive Pericarditis: Pathogenesis & Etiologies

  • Pathogenesis
  • Etiologies

  • Pathogenesis
    • Thickened, fibrous pericardium (sometimes calcified) adheres to atria & ventricles
    • Increases ventricle stiffness
    • Atria require higher venous pressures to fill the ventricles
  • Etiologies
    • Idopathic / viral
    • Pyogenic
    • Tuberculosis
    • Neoplasm
    • Radiation

17

Constrictive Pericarditis: Clinical Features, Diagnostic Tests, & Treatment

  • Clinical features
    • Jugular venous pressure
    • Pulmonary venous pressure
    • Cardiac output
    • Physical exam
  • Diagnostic tests
    • Echo
    • CXR
    • CT
    • MRI
    • ECG
    • Liver function
  • Treatment

  • Clinical features
    • Elevated jugular venous pressure
      • Kussmaul sign: apparent increase in venous pressure (jugular veins) due to lack of inspiratory fall in venous pressure w/ exaggeration of venous waves
      • Edema
      • Ascites
    • Elevated pulmonary venous pressure
      • Shortness of breath
    • Low cardiac output
      • Fatigue
      • Arterial pressure: low pulse pressure, absent pulsus paradoxus (inspiratory fall in arterial systolic pressure > 10 mmHg)
    • Physical exam
      • Pericardial knock
  • Diagnostic tests
    • Echo
    • CXR: calcified pericardium
    • CT: thickened pericardium
    • MRI: thickened pericardium
    • ECG: atrial fibrillation, low voltage
    • Liver function abnormalities due to liver congestion
  • Treatment
    • Pericardiectomy
    • Diuresis will decrease cardiac output

18

Constrictive Pericarditis: Hemodynamics

  • Systemic & pulmonary venous pressures
  • RV diastolic pressure
  • RV pressure tracing
  • RA pressure tracing

  • Systemic & pulmonary venous pressures
    • Elevated & equal
  • RV diastolic pressure
    • Elevated to > 1/3 of RV systolic pressure
  • RV pressure tracing
    • Early diastolic dip
  • RA pressure tracing
    • Preserved "Y" descent

19

Differential Diagnosis

  • Venous (pulmonary & systemic) pressures are elevated & equal
    • Tamponade
    • Constrictive pericarditis
  • Kussmaul's sign
    • Tamponade
    • Constrictive pericarditis
  • Pulsus paradoxus
    • Tamponade
    • Constrictive pericarditis
  • RV diastolic pressure > 1/3 RV systolic pressure
    • Tamponade
    • Constrictive pericarditis
  • "Y" descend in RA prssure & early diastolic dip in RV pressure tracing
    • Tamponade
    • Constrictive pericarditis

  • Venous (pulmonary & systemic) pressures are elevated & equal
    • Tamponade: yes
    • Constrictive pericarditis: Yes
  • Kussmaul's sign
    • Tamponade: absent
    • Constrictive pericarditis: may be present
  • Pulsus paradoxus
    • Tamponade: present
    • Constrictive pericarditis: usually absent
  • RV diastolic pressure > 1/3 RV systolic pressure
    • Tamponade: yes
    • Constrictive pericarditis: yes
  • "Y" descend in RA prssure & early diastolic dip in RV pressure tracing
    • Tamponade: yes
    • Constrictive pericarditis: exaggerated

20

Differential Diagnosis

  • Extra cardiac manifestations
    • Restriction
    • Constriction
  • CXR calcification
    • Restriction
    • Constriction
  • Echo
    • Restriction
    • Constriction
  • CT/MRI
    • Restriction
    • Constriction
  • Cardiac catheterization
    • Restriction
    • Constriction
  • Endomyocardial biopsy
    • Restriction
    • Constriction

  • Extra cardiac manifestations
    • Restriction: of amyloidosis or hemochromatosis etc. may be present
    • Constriction: none
  • CXR calcification
    • Restriction: absent
    • Constriction: may be present
  • Echo
    • Restriction: granular sparkling texture of myocardium in amyloidosis
    • Constriction: thickened pericardium
  • CT/MRI
    • Restriction: pericardium usually normal
    • Constriction: pericardium may be thickened
  • Cardiac catheterization
    • Restriction: LVEDP - RVEDP > 5 mmHG
    • Constriction: LVEDP + RVEDP
  • Endomyocardial biopsy
    • Restriction: may show specific pathology
    • Constriction: may be normal or nonspecific changes