Pericardial Disease Flashcards by Danielle Himelfarb

What are the two layers of the pericardium?

Visceral pericardium - inner serosal layer

Parietal pericardium - outer fibrous layer

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What happens to the intrapericardial pressure (i.e. the pressure on fluid in pericardium) with breathing?

Negative pressure on inspiration
Positive pressure on expiration

But normally should only vary +/- 5 mm Hg

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What is the definition of pericarditis?

Inflammation of pericardium

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What are the two types of causes of acute pericarditis and which is more common?

Infectious - more common

Non-infectious

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What type of infections cause acute pericarditis and which is more common?

Viral - more common
TB
Pyogenic bacteria

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Which viruses typically cause viral (“idiopathic”) pericarditis?

Echovirus

Coxsackie B

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Is it helpful to get viral titers of someone with acute pericarditis?

By the time results are available, symptoms have abated

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How does acute pericarditis appear?

Serofibrinous pericarditis - plasma proteins like fibrinogen, rough & shaggy, red and inflammed
“Bread and butter”

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What are clinical features of acute pericarditis?

Pleuritic chest pain - relieved by leaning forward, sitting up
Fever
Pericardial friction rub - 3 components
EKG abnormalities

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Describe the pericardial friction rub that occurs in acute pericarditis

Will have scratching sounds when ventricles contract and relax, and when atria contract (3 components)
Sounds like creaking leather

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Describe the EKG abnormalities that occur in acute pericarditis

DIFFUSE ST elevation in all leads

PR depression - subtle, diagnostic of pericarditis

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What is the treatment for acute pericarditis?

Self limiting - only need bed rest and NSAIDs

AVOID anticoagulants - will bleed into pericardium

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What organisms will cause purulent pericarditis?

Staph and other gram negative rods

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How does purulent pericarditis appear?

Intense inflammatory response

Serosa is erythematous and coated with purulent exudate

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How does hemorrhagic pericarditis appear?

Gross blood in pericardium

Usually due to trauma, TB, or cancer

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What is the treatment for purulent pericarditis?

Catheter drainage
Antibiotics

Mortality very high

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What is the treatment for TB pericarditis?

Anti-TB meds

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What are possible non-infectious causes of pericarditis?

Post MI
Uremia
Cancer
Radiation induced
Connective-tissue disease
Drug-induced

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What are the two forms of post MI pericarditis?

Early form - hear rub in 10-15% of STEMI patients

Late form - Dressler’s syndrome
Hear rub 2 weeks-several months after STEMI, possible autoimmune related

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Which cancers typically can cause non-infectious pericarditis?

Lung
Lymphoma
Breast

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Which connective-tissue disorders can cause non-infectious pericarditis?

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Lupus

Rheumatoid arthritis

Which drugs can cause non-infectious pericarditis?

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Procainamide

Hydralazine

What volume of pericardial fluid qualifies as pericardial effusion?

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> 50 cc

What are characteristics of transudate?

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Clear fluid
Low protein content
Filtrate across vascular wall
Non-inflammatory

What are characteristics of exudate?

Increased vascular permeability High protein content Fibrous, bloody, or pus Infection, cancer, collagen vascular

What are the three major organs/organ systems that cause transudates?

``` Heart failure (CHF) Liver failure (cirrhosis) Renal failure (nephrotic syndrome) ```

What is a hemopericardium effusion?

Free blood in the effusion | = rupture

What is a chylopericardium effusion?

``` Free chyle (milky) in the effusion = lymphatic obstruction by cancer, inflammation, injury to lymphatics ```

What are the symptoms of pericardial effusion?

NONE - asymptomatic

What are clinical features of a pericardial effusion?

Reduced heart sounds Inability to feel apical beat Ewart's sign - dullness over posterior lung But these can be absent if effusion isn't very large

What is the most useful tool to diagnose a pericardial effusion?

Echocardiogram

What is the definition of cardiac tamponade?

Hemodynamic abnormalities that result from accumulation of pericardial effusion UNDER PRESSURE

What occurs to the diastolic pressures ("filling pressures") when there is tamponade?

Equalization of all filling pressures Diastolic pressures can not be less than the pericardial pressure that is compressing them

What are the hemodynamic consequences of an equalization of filling pressures in tamponade?

Equalization of pressures --> decrease in filling of ventricles --> SV decreases --> CO decreases --> hypotension, shock, death

What is the most important factor in determining how high the pressure gets in the pericardium?

Rate of accumulation | i.e. get tamponade acutely from hemorrhage, pressure will skyrocket quickly

What are causes of tamponade?

``` Anything that causes acute pericarditis Cancer Uremia Post viral Hemorrhage ```

What is the classic triad of clinical signs of tamponade?

Beck's triad Increased venous pressure Hypotension (from the decreased CO) Diminished heart sounds

What is the most important physical finding in tamponade?

Pulsus paradoxus

Describe the phenomenon of pulsus paradoxus

Decrease in systolic BP > 10 mm Hg during NORMAL inspiration When you inspire, lungs take up a little more blood, so have slightly less blood returning to LA. In normal people, this only changes BP by ~1-2 mm Hg. In tamponade, this is >10 mm Hg.

What are clues to tamponade on echocardiogram?

Pericardial effusion (can't have tamponade without effusion!) RA collapse RV collapse Dilated IVC (backup of blood since chambers can't expand)

What are clues to tamponade on EKG?

Electrical alternans (amplitude of QRS varies from beat to beat) Due to movement of effusion fluid

What is the definitive test to define tamponade that is done in the cath lab?

Measure diastolic pressures of all chambers | Equalization of diastolic pressures = tamponade

How do you treat cardiac tamponade?

Pericardiocentesis - stick needle in, extract fluid Pericardial window - cut window for fluid to exit Pericardiotomy - remove entire pericardium

What is constrictive pericarditis?

"Egg shell disease" | Thick and stiff pericardium around the heart

What are causes of constrictive pericarditis?

TB Surgery - bleeding in pericardium can scar over time and become stiff Radiation

What other pathology can constrictive pericarditis look like and how could you differentiate?

``` Appears like tamponade Be suspicious if patient exhibits: - Heart failure - Liver cirrhosis - Intra-abdominal tumor ```

What are clues of constrictive pericarditis on physical exam?

Pericardial knock Prominent "y" descent in jugular vein Kussmaul's sign

On a chest xray, what is diagnostic of constrictive pericarditis?

Pericardial calcification | Looks like an egg shell around heart

What are clues of constrictive pericarditis on pressure curve?

Square root sign - "dip and plateau" Heart can only dilate through first third of diastole, but 'egg shell' stops it from dilating through the rest of diastole This is what causes the pericardial knock heard

How do you treat constrictive pericarditis?

Surgery

Pericardial Disease Flashcards

(50 cards)