Pericardial Diseases - Exam 1

Question 1

What is the role of the pericardium?

Answer 1

double-layered sac surrounding the heart that restricts the anatomic position of the heart. Decreases the spread of infections from the lungs and pleural cavities to the heart

Question 2

a large portion of pericarditis causes are ______. What is the MC?

Answer 2

no identifiable cause

viral are the MC cause

Question 3

When bacterial endocarditis does occur _____ is the likely culprit

Answer 3

extension of pulmonary infections

Question 4

cancer pericarditis is either going to be _____ or ______. Why?

Answer 4

lung or breast

they both are in close proximity

Question 5

name 4 pericardial injuries that can cause pericarditis

Answer 5

invasive cardiac procedures

post-pericardiotomy

trauma

radiation

Question 6

**What is Dressler syndrome? What is the tx?

Answer 6

pericarditis that occurs 2 weeks after a MI due to an autoimmune/inflammatory response

usually self limiting

Question 7

What are the 4 main diagnostic features of pericarditis?

Answer 7

chest pain

pericardial friction rub

EKG

pericardial effusion

Question 8

**What is the cardinal symptom of pericarditis? Where? Is it pleuritic? What makes it worse? better?

Answer 8

Chest pain caused by the heart rubbing against the pericardium

Usually precordial or retrosternal with referral to the trapezius ridge, neck, left shoulder, or arm

PLEURITIC

worse: lying flat, swallowing, coughing, body movement

better: sitting up and leaning forward

Question 9

What is the characteristic heart sound associated with pericarditis?

Answer 9

pericardial friction rub

Question 10

What is a EKG finding that would point to pericarditis?

Answer 10

diffuse ST segment elevation (aka ST segment elevation everywhere NOT just in specific boxes that would indicate MI)

Question 11

What is the diagnostic criteria for acute pericarditis?

Answer 11

need at least 2:

Typical chest pain - pleuritic, worse with lying down, improved with sitting/leaning forward

Pericardial friction rub

Characteristic ECG changes

New or worsening pericardial effusion

Question 12

What is the tx for acute pericarditis? _____ should be used in post-MI cases. ________ is used in severe/refractory cases or when the first line agent is CI

Answer 12

Ibuprofen or Indomethacin for 14 days

+/- colchicine as adjuvant

ASA is preferred post-MI

Prednisone

Question 13

Because the pericardium covers the ascending aorta and arch, _______ can also lead to a pericardial effusion/ tamponade

Answer 13

aortic dissection / rupture

Question 14

What is cardiac tamponade? What does it depend on?

Answer 14

increased pressure around the heart

no specific amount of fluid but depends on the RATE of ACCUMULATION

Question 15

What does cardiac tamponade lead to?

Answer 15

the right atria is usually the first to collapse due to increased pressure which leads to reduced cardiac output and potentially cardiogenic shock = medical emergency

Question 16

What does the presentation of cardiac tamponade depend on? Give both options

Answer 16

presentation is based on the size of the effusion

small: asymptomatic or s/s of pericarditis

large: chest pain, fatigue, SOB

aka super bad cardiac tamponade will have s/s of cardiogenic shock

Question 17

**What is Beck’s triad? What is it associated with?

Answer 17

Beck’s triad: classic presentation of cardiac tamponade

JVD
Muffled Heart Sounds
Hypotension

Question 18

What is Kussmaul’s sign?

Answer 18

increase in JVP on inspiration (instead of the normal decrease)

cardiac tamponade

Question 19

What is pulsus paradoxus?

Answer 19

an inspiratory systolic fall in arterial pressure >12 mmHg during normal breathing (check BP with inspiration) – 70-80% of patients

Question 20

What are the 2 highlighted s/s of pericardial effusion?

Answer 20

Pericardial friction rub
Narrow pulse pressure

plus look for all the s/s of cardiogenic shock

Question 21

What is the initial test of choice to dx pericardial tamponade? What 3 things should you look for on said test?

Answer 21

Echo TTE

RV Collapse
LV Collapse
Dilated IVC w/out inspiratory collapse

Question 22

**The CXR of cardiac tamponade will often have _______. What does it indicate?

Answer 22

water bottle heart

fluid accumulation around the heart

Question 23

**What is the EKG finding associated with pericardial effusion? What is it a result of?

Answer 23

ELECTRICAL ALTERNANS is pathognomonic of cardiac tamponade.Characterized by alternating levels of ECG voltage of the p wave, QRS complex, and T waves

This is the result of the heart “swinging” in a large effusion

Question 24

Why would you order a CT in pericardial effusion? What is an advantage?

Answer 24

provides anatomic details of the entire pericardium due to its capacity in providing a wide field of view. Advantages include its capacity to detect pericardial calcifications.

Question 25

Why would you order a MRI in pericardial effusion? What type of pt is it NOT good for?

Answer 25

provides anatomic details of the pericardium and heart without ionizing contrast or radiation. Sensitive for detecting pericardial effusion and loculated pericardial effusion and thickening Limited use in patients with arrhythmias

Question 26

What is the management for small effusions? What is considered small?

Answer 26

serial echos Usually <1cm in size

Question 27

What is the criteria for pericardial effusion that requires hospital admission?

Answer 27

large effusions >2cm Fever (>38ºC [100.4ºF]) and leukocytosis Immunosuppressed state A history of therapy with V-K antagonists Acute trauma Failure to respond within seven days to NSAID therapy Elevated cardiac troponin, which suggests myopericarditis

Question 28

When would pericardiocentesis be a good management option?

Answer 28

For effusions >250 mL, effusions when size increases despite intensive dialysis for 10-14 days, or effusions with evidence of tamponade considered diagnostic and therapeutic

Question 29

What are the 4 pericardial effusion tx options?

Answer 29

Pericardial Diodesis Pericardiotomy Pericardial Window Pericardiectomy

Question 30

What is happening in Pericardial Diodesis (Sclerotherapy)?

Answer 30

Installation of chemical in the pericardial space causing sclerosis of the pericardium - essentially eliminates the space between the heart and the pericardium so fluid can no longer accumulate

Question 31

What is happening in a Pericardiotomy?

Answer 31

Incision made into the pericardium. Effective (90-97%)

Question 32

What is happening in pericardial window?

Answer 32

A surgical procedure to create a fistula - "window" - from the pericardial space to the pleural cavity, allowing the effusion to drain out of the pericardial space into the chest cavity. Can be performed with a balloon catheter.

Question 33

What is happening in a pericardiectomy?

Answer 33

Removal of the pericardium itself. The most effective surgical procedure for managing large effusions, but since it requires general anesthesia and a thoracotomy, only consider if pericardiotomy can’t be performed or has been unsuccessful

Question 34

What is constrictive pericarditis caused by?

Answer 34

Inflammation of the pericardium can lead to a thickened, fibrotic, adherent pericardium that restricts DIASTOLIC filling which will present as right sided heart failure

Question 35

____ is the most common cause of constrictive pericarditis in developing countries. **What are the 3 MC causes in developed countries?

Answer 35

TB Radiation cardiac surgeries viral pericarditis

Question 36

How will constrictive pericarditis present? What phase of the cardiac cycle is most affected?

Answer 36

Progressive dyspnea, fatigue and weakness Edema, ascites, hepatic congestion Elevated JVP – Kussmaul sign Atrial fibrillation is common (presents like right sided heart failure) DIASTOLIC function is most affected

Question 37

constrictive pericarditis presents similarly to other heart conditions, need to order ______ to confirm diagnosis.

Answer 37

cardiac cath to measure pressures in the right and left ventricle during inspiration and expiration

Question 38

What is the tx for constrictive pericarditis? What is that doesnt work?

Answer 38

Diuretics!! loop or aldosterone antagonists Surgical pericardiectomy is recommended for patients unresponsive to diuretics