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Flashcards in Pericardial Disease Deck (26):
1

What are the four types of pericardial disease?







• Acute pericarditis
• Pericardial effusion without hemodynamic compromise
• Cardiac tamponade
• Constrictive pericarditis

2

What's the treatment of acute pericarditis?

• Treat with ibuprofen 300-800mg PO every 6-8 hours
• Aspirin 325-650mg is alternative, but ibuprofen is first round treatment

3

If you see ST segment elevation in a pt with actue chest pain that varies with positioning…..

• Acute pericarditis
• Treat with ibuprofen 300-800mg PO every 6-8 hours
• Aspirin 325-650mg is alternative, but ibuprofen is first round treatment

4

How do you make the acute pericarditis diagnosis?

• Chest pain varies with position and breathing
• Pericardial rub on cardiac exam
• ECG - diffuse ST elevation
• ECHO - pericardial fluid
• Response to anti-inflammatory agents

5

What is the most common presentation of acute pericarditis?

• Sudden onset chest pain (severe)
• Chest pain varies with position and breathing

6

What are the common causes of acute pericarditis?

• Viral illness
• Connective tissue or autoimmune diseases
• Uremia
• Metastaic tumors

7

What is going on in constrictive pericarditis?

• Chronic process, pericardium thickens to the point where it compresses the heart
• Compression leads to limited cardiac output

8

What is going on in cardiac tamponade?

• Excessive pericardial fluid compresses the heart and reduces CO
• Acute emergency

9

What causes constrictive pericarditis?


• Scarring and loss of elasticity of the pericardium
○ Idiopathic, cardiac surgery, ratiation, infection
• Results in impaired diastolic filling with normal systolic function
• Presents as an elevated jugular venous pressure, hepatomegaly, eema, ascities, tachycardia
• Diagnosed by echo, CXR
○ See thickened or calcified pericardium

10

What is the treatment of constrictive pericarditis?

• Surgical stripping of the pericaridum

11

What are the clinical points in constrictive pericarditis?

• Chronic disease, not really an acute deal
• Cardiac sillouette is normal size but encased by thickened pericardium
• Lungs are not congested
○ Selective obstruction of RIGHT ventricle filling
• Often mistaken for liver disease because prolonged high venous presure causes hepatic enlargement and ascites

12

How can you distinguish between pericardial pain and other causes of chest pain?




• Classic distinguishing factors of pericardial pain are "pleuritic" and "positional"
○ Pain increased with deep breathing
○ Pain is relieved by sitting up or other postural changes
• Coronary syndromes (acute) do not show pleuritic changes in pain (breathing, cough, position don't change pain)
• PE pain may be pleuritic but lacks ECG changes of pericarditis or pericardial rub (stethoscope finding)
○ Often occurs in conjunction with risk factors of recent surgery or long periods of inactivity
• Pneumonia may present with pleuritic pain, but there are usually localized rales in lung fields (pericardial problems have clear lung fields)

13

What is seen as COMMON between pericardial tamponade and CHF?

• They BOTH have
○ Distended neck veins, tachycardia, low blood pressure, large cardiac silhouette on CXR

14

What is the difference between CHF and pericardial tamponade in terms of pulsus paradoxus?

• Tamponade - lungs are clear on exam and CXR
§ Pulsus paradoxus is expected here
• CHF - lungs are congested on exam and CXR
§ Pulsus paradoxus is rare here

15

How can you distinguish between pericardial tamponade and congestive heart failure?

• Tamponade - major impairment is right heart filling during diastole
• CHF - no impairment in right heart filling but diminished myocardial funciton causes pulmonary and systemic congestion
○ So, CONGESTION is seen in CHF but not in Tamponade
• They BOTH have
○ Distended neck veins, tachycardia, low blood pressure, large cardiac silhouette on CXR
• DIFFERENCES
○ Tamponade - lungs are clear on exam and CXR
§ Pulsus paradoxus is expected here
○ CHF - lungs are congested on exam and CXR
§ Pulsus paradoxus is rare here

16

What are the other emergent chest pain things you need on a differential of pericardial disease?

• Coronary syndroms
• DVT/PE
• Pneumonia

17

In terms of heart sounds, what are the differences in exam findings between cardiac tamponade and CHF?






• Tamponade - heart sounds "distant" and apex not palpable
• CHF - heart sounds more likely to be normal volume, just added sounds as well
○ Murmurs and S3 presence, ventricular lifts

18

What are the differences between pericardial tamponade and constrictive pericarditis?

• Tamponade
○ Large cardiac silhouette on CXR
○ Pulsus paradoxus present
○ Develops more acutely and does not have the chronic problems like hepatic congestion, ascites and edema
○ Echocardiogram reveals marked pericardial effusion and right atrial collapse on inspiration
• Constricitve
○ Normal silhouette on CXR, though some calcification may be seen on CXR
○ Pulsus paradoxus very rare
○ Slow development and accompanied by hepatic congestion, ascites and marked pedal edema
○ Echocardiogram does not demostrate pericardial fluid, right atrial collapse with inspiration

19

What are the features in common between pericardial tamponade and constrictive pericarditis?

• Reduced diastolic function with preserved systolic function
• Jugular venous distention
• Tachycardia and tendency to low blood pressure

20

What are the echocardiogram findings of CHF?

• Poor contractile funciton and dilation of the ventricles
• Tamponade findings are absent

21

What are tamponade findings by echocardiogram?

• Large pericardial effusion
• Right atrial collaps
• Lack of normal decrease in inferior vena cava diameter

22

When would you expect to find low voltage and pulsus alternans?

• Pulsus alternans is a CHF-associated physical exam finding.
*Pulsus alternans is a physical finding with arterial pulse waveform showing alternating strong and weak beats. It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis.
*RARELY SEEN IN TAMPONADE

23

what are the findings in pericardial tamponade?

• Tamponade
○ Large cardiac silhouette on CXR
○ Pulsus paradoxus present
○ Develops more acutely and does not have the chronic problems like hepatic congestion, ascites and edema
○ Echocardiogram reveals marked pericardial effusion and right atrial collapse on inspiration

24

what are the findings in constrictive pericarditis?

• Constricitve
○ Normal silhouette on CXR, though some calcification may be seen on CXR
○ Pulsus paradoxus very rare
○ Slow development and accompanied by hepatic congestion, ascites and marked pedal edema
○ Echocardiogram does not demostrate pericardial fluid, right atrial collapse with inspiration

25

What is pulsus paradoxus?

• Greater than 10mmHg drop in systolic pressure during inspiration

26

Whas is Pulsus paradoxus and where would you expect to find it?

Pulsus paradoxus (PP), also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mm Hg. When the drop is more than 10 mm Hg, it is referred to as pulsus paradoxus. Pulsus paradoxus is not related to pulse rate or heart rate and it is not a paradoxical rise in systolic pressure. The normal variation of blood pressure during breathing/respiration is a decline in blood pressure during inhalation and an increase during exhalation. Pulsus paradoxus is a sign that is indicative of several conditions, including cardiac tamponade, pericarditis, chronic sleep apnea, croup, and obstructive lung disease (e.g. asthma, COPD).[1]