Pericardial Disease

Question 1

Most common cause of acute pericardial disease?

Answer 1

Idiopathic

Question 2

Causes of Pericarditis

Answer 2

Radiation
Neoplasm
Trauma
Autoimmune
Metabolic (Hyperthyroidism, Uremia)

Question 3

Viral causes of Pericarditis?

Answer 3

Coxsackie A or B, Echovirus, Mumps, Adenovirus, and HIV

Question 4

Bacterial causes of Pericarditis?

Answer 4

TB, pneumococcus, streptococcus, staphylococcus, legionella

Question 5

Fungal causes of Pericarditis?

Answer 5

Histoplasmosis, Coccidiomycosis, Candidiasis, Blasto

Question 6

Cardiac causes of Pericarditis?

Answer 6

Early infarction pericarditis
Late post cardiac injury (Dresslers’)
Myocardiits
Dissecting aortic aneurysm

Question 7

Drugs that cause Pericarditis?

Answer 7

Procainamide
Isoniazid
Hydralazine

Question 8

Acute Pericarditis pathologic anatomy

Answer 8

Usually fluid accumulation – usually serous
Bacteria (Purulent) and Tumor Cells
Fluid may resolve or form adhesions

Question 9

Chronic Pericarditis pathologic anatomy

Answer 9

Roughened Heart Surface

Bread and Butter

Question 10

Clinical Features of Pericarditis?

Answer 10

Chest Pain
Pericardial Friction Rub
ECG Changes
Pericardial Effusion

Question 11

Acute Pericarditis Chief Complaints

Answer 11

Chest Pain unrelated to exertion
Fatigue, Dyspnea, Malaine
Fever

Question 12

Describe the chest pain of Acute Pericarditis?

Answer 12

Sharp, Stabbing, Sudden Onset
Worse on deep inspiration and lying flat
Better Leaning Forward

Question 13

Describe a Pericardial Rub

Answer 13

From friction btw layers of pericardium
Superficial, scratchy, leathery sound – higher than diastolic filling sounds
Best heard over left sternal border

Question 14

Acute pericarditis findings

Answer 14

Typical history, exam ECG
Normal CXR most of the time
Autoimmune serologies
Pericardiocentesis if you suspect infection or cancer

Question 15

What EKG changes are expected with Acute Pericarditis? (Overall)

Answer 15

Sinus Tachy
Diffuse Concave ST changes
PR depression
PR elevtion+ST depression in aVR
Diffuse -- not associated with a specific vessel

Question 16

EKG changes 4 stages

Answer 16

1. Hours to Days - Diffuse ST Elevation, PR depression
2. First week – Normalization of ST and PR
3. Diffuse T wave inversions
4. Normalization of EKG or indefinited persistence of inversions (in chronic)

Question 17

Complications of Acute Pericarditis?

Answer 17

Pericardial Effusion and Tamponade
Constrictive Pericarditis
Relapse

Question 18

Idiopathic and Viral Pericarditis Treatment?

Answer 18

Combination of NSAIDS (2 weeks) and Colchicine (3 months)

Question 19

Treatment for Pericarditis Post Acute MI

Answer 19

Aspirin and Colchicine

Question 20

Who can’t have Colchicine?

Answer 20

No good with severe renal or liver disease, blood dyscrasias, or GI motility disorders

Question 21

What do you give to patients with symptoms refractory to standard therapy? Whats the problem?

Answer 21

Glucocorticoids

Increased risk of recurrence

Question 22

Causes of Pericardial Effusion

Answer 22

Acute Pericarditis
Radiation
Malignancy
Cardiac Perforation
Hypothyroid
Connective Tissue Disease
Aortic Dissection

Question 23

What is electrical alternans

Answer 23

Alternating large spikes in EKG from heart swinging around in the fluid filled sack

Question 24

X ray Pericardial Effusion findings

Answer 24

Massive looking heart

Question 25

Pericardial Tamponade Presentation?

Answer 25

CHF symptoms with clear lungs Unexplained signs of R Heart Failure (Edema, JVP) Cardiomegaly on CXR Sinus Tachy, Electrical Alternans

Question 26

Pericardial Tamponade Pathophysiology?

Answer 26

Fluid Increases pericardial pressure Pressure impedes diastolic filling of LV and RV RV and LV diastolic pressure rises SV and CO decrease Systemic BP drops, pulse pressure narrows, HR up

Question 27

What is Pulsus Paradoxus?

Answer 27

Fall of systolic BP of over 10 mmHg with inspiration

Question 28

Why does Pulsus Paradoxus happen?

Answer 28

Inspiration increases venous inflow to RV, RV expansion. W/ compressive fluid, the increase in return causes a septal shift, impinging on LV volume.

Question 29

Physical findings in Pericardial tamponade?

Answer 29

``` Sinus tachycardia Hypotension (late w/ narrow Pulse Pressure) Elevated JVP w/ loss of Y descent Edema Pulsus Paradoxus ```

Question 30

Three ECG findings of pericardial tamponade

Answer 30

Sinus tachycardia Low Voltage Electrical alternans

Question 31

Important unique component of Pericardial Evaluation

Answer 31

Right heart catheterization (Equalization of pressures)

Question 32

Treatment for Pericardial Tamponade

Answer 32

``` Medical Emergency IVF (temporizing) AVOID diuretics, vasodilators Vasopressors Pericardiocentesis/Window ```

Question 33

What is Constrictive Pericarditis?

Answer 33

Chronic thickening/scarring of pericardium leads to encasement of the heart and impaired diastolic filling of LV and RV.

Question 34

Name for the sign associated with constrictive pericarditis

Answer 34

Dip and Plateua or Square Root sign

Question 35

Most common cause of Constrictive Pericarditis

Answer 35

Idiopathic or Viral

Question 36

Clinical Presentation of Constrictive Pericarditis

Answer 36

``` Slow, indolent process Unexplained RHF (JVP w/ X and Y) Often misdiagnosed as Cirrhosis ```

Question 37

What is Kussmaul's Sign?

Answer 37

Rise in JVP with Inspiration

Question 38

How are the jugular venous patterns between tamponade and constriction

Answer 38

Tamponade -- No Y | Constriction -- Kept the X and Y

Question 39

Pericardial Knock comes from...

Answer 39

Rapid Atrial Filling

Question 40

Which side of the heart is more influenced by constrictive Pericarditis?

Answer 40

Simutaneous L and R heart -- Equalized diastolic pressures

Question 41

Therapy for constrictive pericarditis?

Answer 41

Diuretics (but don't drop the filling pressure too low!) | Pericardial Stripping