Pericardial disease Flashcards
(66 cards)
1
Q
pericardium
A
visceral and parietal layer with pericardial cavity between them
2
Q
how much fluid is in the pericardium?
A
15-50ml
3
Q
pericarditis
A
inflammation of pericardium
- acute and recurrent pericarditis
- pericaridal effusion without major hemodynamic compromise
- cardiac tamponade
- constrictive pericarditis
4
Q
acute pericarditis
A
rapidly inflammation of pericardium
5
Q
causes of pericarditis
A
radiation neoplasms: primary, metastatic, or paraneoplastic trauma autoimmune metabolic: hypothyroidism, uremia
6
Q
infection causes
A
viral
Bacterial:
fungal:
AIDS
7
Q
infection causes: viral
A
coxsackie, echovirus, mumps, adeno, HIV
8
Q
bacterial causes
A
TB, pneuomococcus, strept, staph, legionella
9
Q
infection causes: fungal
A
histoplasmosis, coccidioidomycosis, candida, blastomycosis
10
Q
cardiac causes of pericarditis
A
- early infarction
- late post cardiac injury (Dressler’s)
- myocarditis
- resulting from dissecting aortic aneurysm
11
Q
drugs that cause pericarditis
A
procainamide
isoniazide
hydralazine
12
Q
etiology of acute pericarditis
A
most idiopathic vial neoplastic TB/histoplasmosis radiation purulent (bacterial) connective tissue disease post-myocardial infarction uremia
13
Q
pathological anatomy of acute pericarditis
A
- usually fluid accumulation
- bacterial or tumor
- sometimes bacterial infection causes purulent pericarditis
- fluid may resolve or form adhesions
14
Q
chest pain
A
present most the time
sudden onset
anterior chest wall
sharp, pleuritic in nature: inflammation of lining of lungs
worse with laying flat, inspiration or coughing
better when seated, leaning forward
15
Q
presentation of acute pericarditis
A
chest pain (unrelated to exertion)
fatigue, dyspnea, malaise
fever
-can mimic onset of the flu
16
Q
what causes the pericardial friction rub
A
friction between the two inflamed layers of pericardium
- scratchy, leathery sound-> high pitch than diastolic filling sounds
- triphasic or biphasic
- can come and go, very in intensity
17
Q
when is it best to hear the pericardial friction rub?
A
diaphragm over left sternal border
-patient sitting upright or leaning forward
18
Q
evaluation for acute pericarditis
A
ESR, CBC, blood chemistries -CXR usually normal echo viral studies autoimmune serologies pericardiocentesis if suspect purulent pericarditis, malignancy or large effusion
19
Q
evaluation for acute pericarditis
A
- history, ECG, exam
- ESR, CBC, blood chemistries
- CXR usually normal
- echo
- viral studies
- autoimmune serologies
- pericardiocentesis if suspect purulent pericarditis, malignancy or large effusion
20
Q
what is seen on ECG with acute pericarditis
A
seen with visceral inflammation of pericardium
ST and PR segment change:
-convex shape for ST segment
-diffuse ST elevation (acute pericarditis): I, II, III, aVF, V2-6
-PR depression: II, III, aVF
-aVR ST depressions
-aVR PR segment elevation
21
Q
what is important to do on physical exam for chest pain
A
- ask where it hurts
- press on the spot-> to see if its musculoskeletal
22
Q
ECG stages in pericarditis: Stage 1
A
first hours to days
-ST elevation and PR depression
23
Q
ECG stages in pericarditis: Stage 2
A
first week
normalization of ST and PR segment
24
Q
ECG stages in pericarditis: Stage 3
A
T wave inversions, AFTER ST have become isoelectrical
25
ECG stages in pericarditis: Stage 4
hjj
26
complications of acute pericarditis
1. pericardial effusion and tamponade
2. constrictive pericarditis (late)
3. relapse
27
early repolarization will be seen in
I, aVL, V4-6
| -ST elevation seen more in V4-6
28
acute pericarditis ECG summary
- sinus tachycardia
- diffuse concave ST elevations
- PR segment depression
- PR elevation and ST depression in aVR
29
medical therapy for viral or idiopathic pericarditis
-combination of NSAID's and colchicine (3 months)
-NSAIDs (high dose)
indomethacin, ibuprofen
-for 2 weeks
30
pericarditis post Acute MI
aspirin and colchicine
| avoid NSAIDs, interfere with healing and scar formation
31
colchicine
take for 3 months
- 8% diarrhea
- metabolized by CYP, watch for drug interactions
- not good with severe renal or liver disease, blood dyscrasias or GI motility disorders
32
watch giving NSAID's because
renal insufficiency
administer with food
Proton pump inhibitor with long term use
33
glucocorticoids
- patients with symptoms refractory to standard therapy
- acute pericarditis due to connective tissue disease
- uremic pericarditis
34
treatment for acute pericarditis
high dose aspirin
NSAIDs
steroids
colchicine
intensified hemodyalsis for uremic pericarditis
pericardiocentresis for tamponade or purulent
35
pericardial effusion
accumulation of fluid in pericardial space
| pushes on heart and creates tamponade
36
causes of pericardial effusion
```
acute pericarditis
radiation
malignancy
cardiac perforation
hypothyroidism
connective tissue disease
post-myocardial
chronic renal failure
aortic dissection
```
37
what seen on ECG for pericardial tamponade
- tachycarida
- low QRS voltage in all leads-> small amplitudes
- see electrical alternans
38
what do you see on ECG with pericardial effusion (tamponade)?
-electrical alternans
39
pathophysiology of pericardial tamponade
- pericardial fluid increases intrapericardial pressure
- increased intrapericardical pressure impedes diastolic filling LV and RV
- RV and LV diastolic pressure rises
- stroke volume decreases
- cardiac output decrease
- systemic BP drops, pulse pressure narrows, and heart rate increases
40
presentation pericardial tamponade
- depends on chronicity of process
- CHF symptoms with clear lungs
- unexplained signs of right jugular heart failure: edema and increased JVP
- new cardiomegaly on CXR
- sinus tachycardia, low voltage, electrical alternans on ECG
41
what is pulse paradoxus
-exaggerated drop in systemic blood pressure during inspiration is termed pulsus paradoxus
42
pulsus paradoxus
- systemic arterial pressure normally falls by less than 10 mmHg during inspiration
- fall of systolic blood pressure of >10mmHg with inspiration
43
in pulsus paradoxus, on inspiration
the LV gets compressed
44
in pulsus paradoxus, on expiration
the LV expands
45
physical findings of pericardial tamponade
```
sinus tachycardia
tachypnea
hypotension (late) with narrow pulse pressure
elevated JVP with loss of Y descent
edema
pulsus paradoxus
```
46
mechanism of pulsus paradoxus in tamponade
increased ventricular interdependence
Normally: inspiration increases venous inflow to the RV, RV free wall expands
In tamponade: Inspiration increases venous inflow to the RV, RV free wall cannot expand
- diminished stroke volume with inspiration
- inspiratory increase in venous return--> causing septal shift imprinting on LV volume
47
evaluation of pericardial tamponade
```
history and exam
ECG, CXR
emergent echo with doppler
right heart catheterization
pericadriocentesis
```
48
pericardial tamponade treatment
```
medical emergency
pericadriocentesis
IVF
vasopressors as needed
pericardial window
Prompt pericardiocentesis
```
49
what to avoid in pericardial tamponade
diuretics, vasodilators, etc.
50
what would be in pericardial analysis of fluid?
gram stain and bacterial and fungal culture
cytology
AFB stain and mycobacterial culture along with adenosine deaminase, interferon-gamma or lysosome (for TB)
PCR
protein, LDH, glucose, RBC, WBC
51
labs for pericardial tamponade
```
cardiac enzymes
inflammation markers (C-reactive proteins, ESR, WBC)
thyroid function
renal function studies
body fluid cultures
TB skin test
```
52
constrictive pericarditis etiology
```
idiopathic viral
post cardiac surgery
radiation therapy
connective tissue disease
post TB, bacterial
miscellaneous
```
53
pathophysiology of constrictive pericarditis
chronic thickening/scarring of pericardium leads to encasement of heart and impaired diastolic filling of LV and RV
- early diastolic filing unimpaired
- chambers expand and collide with unyielding pericardium which halts further diastolic filling
- dip and plateau or square root sign
54
clinical presentation constrictive pericarditis
slow, indolent process
unexplained right heart failure: systemic congestion, fatigue, dyspnea
Often misdiagnosed as cirrhosis
55
what is constrictive pericarditis misdiagnosed for?
cirrhosis
56
unexplained right heart failure with constrictive pericarditis involves?
systemic congestion: edema, ascites, hepatomegaly
fatigue
dyspnea
57
physical findings of constrictive pericarditis
elevated JVP with prominent X and Y descents
Kussmaul's sign
pericardial knock
systemic congestion (hepatomegaly, ascites, edema)
58
what is Kussmaul's sign?
paradoxical rise in jugular venous pressure (JVP) on inspiration
-lack of inspiratory decline in JVP
59
difference between tamponade and constrictive jugular venous pattern?
tamponade: loss of Y descent
constrictive: X and Y descent
60
where would the pericardial knock in constrictive pericarditis be present on ECG?
after T wave
| LA
61
evaluation of constrictive pericarditis
```
history and exam
ECG: low voltage, ST&T wave changes
CXR: pericardial calcifications
chest CT: pericardial thickening
cardiac MRI
echo
simultaneous right and left heart hemodynamics
```
62
what is seen on CXR, that is HALLMARK for constrictive pericarditis
pericardial calcification
| -from chronic pericarditis
63
what is seen on ECG for constrictive pericarditis
low voltage, ST and T wave changes
64
what is seen on chest CT for constrictive pericarditis
pericardial thickening
65
what is meant with simultaneous right and left heart hemodynamics in constrictive pericarditis?
equalization of LV and RV diastolic pressure
66
therapy for constrictive pericarditis?
diuretics
| pericardial stripping
