Pericarditis

Question 1

What is the pericardium?

Answer 1

Fibroelastic sac

Visceral and parietal layers with pericardial cavity between them

15-50 mL of plasma ultrafiltrate

Question 2

Definition of acute pericarditis

Answer 2

Rapidly developing inflammation of the pericardium

Question 3

What is the most common cause of pericarditis?

Answer 3

idiopathic!

Question 4

What are some causes of pericarditis?

Answer 4

Radiation
Neoplasm
Trauma
Autoimmune
Metabolic
   ---Hypothyroidism
   ---Uremia

Question 5

Cardiac causes of pericarditis

Answer 5

Early infarction pericarditis
Last post cardiac injury (Dresslers)
Myocarditis
Dissecting aortic aneurysm

Question 6

What drugs can cause pericarditis? How?

Answer 6

Via drug induced lupus

Procainamide
Isoniazid
Hydralazine

Question 7

Acute pericarditis - important viral, bacterial, and fungal causes

Answer 7

Viral
-coxsackie, echovirus, adenovirus, influenze, HIV

TB/histoplasmosis

Question 8

Acute pericarditis pathologic anatomy

Answer 8

Usually fluid accumulation - most commonly serous

Bacteria or tumor cells

Sometimes bacterial infection causes a purulent pericarditis

Fluid may resolve or form adhesions

Question 9

What sort of change is there is the surface of the heart with pericarditis?

Answer 9

It becomes roughened

–sometimes described as bread and butter pattern

Question 10

Clinical features of pericarditis

Answer 10

Chest pain
Pericardial friction rub
ECG changes
Pericardial effusion

Question 11

Acute pericarditis Presentation - chief complaints

Answer 11

Chest pain unrelated to exertion
Fatigue, dyspnea, malaise
Fever

(so basically flu like symptoms other than chest pain)

Question 12

Type of chest pain seen with acute pericarditis

Answer 12

Sudden onset of pleuritic chest pain

• -sharp, stabbing
• -worse on deep inspiration and laying flat, better leaning forward

Question 13

Pericardial friction rub is due to ..

What does it sound like?

Answer 13

friction between the two inflammated layers of pericardium

Scratchy, leathery sound - higher pitch than diastolic filling sounds

• —best heart with the diaphragm
• —heard over left sternal border

Question 14

ECG findings with acute pericarditis

These changes signify …

Answer 14

Sinus tachycardia

ST elevation and PR depression

• –aVR opposite
• –ST changes are diffuse and not well correlated to acute ischemia or a single vessel

Changes signify inflammation of the epicardium, since the parietal pericardium itself is electrically inert

Question 15

Acute pericarditis complications

Answer 15

Pericardial effusion & tamponade
Constrictive pericarditis (late)
Relapse

Question 16

How do we treat idiopathic and viral causes of pericarditis?

Answer 16

Combination of NSAIDs (2 weeks) and colchicine (3 months)

Question 17

How do we treat pericardicitis post MI?

Answer 17

Aspirin and colchicine

Avoid NSAIDs since they may interfere with healing and scar formation

Question 18

When would glucocorticoids by used in pericarditis?

Answer 18

In patients with symptoms refractory to standard therapy

Acute pericarditis due to CT disease

Uremic pericarditis

(use these rarely and cautiously b/c of concern of recurrence of pericarditis)

Question 19

What is a pericardial effusion?

How does this relate to tamponade?

Answer 19

Accumulation of fluid in pericardial space

Pericardial fluid pushing on the heart creates tamponade

Question 20

What ECG changes are seen with pericardial effusion (and pericardial tamponade)?

Answer 20

1. sinus tach
2. low voltages (of all QRS)
3. electrical alternans

Question 21

What is the presentation of pericardial tamponade like?

Answer 21

• Depends on chronicity of the process
• ‘CHF’ symptoms with clear lungs
• Unexplained signs of R heart failure (edema, increased JVP)
• New ‘cardiomegaly’ on CXR
• ECG changes

Question 22

Pericardial tamponade - pathophysiology

Answer 22

Pericardial fluid increases intrapericardial pressure which impedes diastolic filing of LV and RV

RV and LV diastolic pressure rises
SV and CO decrease
Systemic BPdrops
Pulse pressure narrows
HR increases

Question 23

Pulsus paradoxus

• definition
• what is this seen with?
• what is the mechanism behind this?

Answer 23

Fall of systolic blood pressure > 10 mmHg with inspiration

Seen with tamponade

With compressive fluid, the increase in venous return causes septal shift impinging on LV volume

Question 24

How do we check for pulsus paradoxus?

Answer 24

Can check by measuring the difference in systolic pressure
BUT, shouldn’t do this, instead
listen for the difference in when you start hearing rare korotkof sounds to when you start hearing all of them regularly

Question 25

Physical findings of pericardial tamponade

Answer 25

``` Sinus tach Tachypnea Hypotension (late) with narrow pulse pressure Elevated JVP with loss of Y descent Edema Pulsus paradoxus ```

Question 26

Treatment of pericardial tamponade

Answer 26

``` Medical emergency! IVF (temporizing) Vasopressors as needed Prompt pericardiocentesis Pericardial windown ``` AVOID diuretics, vasodilators, etc.

Question 27

What labs should be done on someone with pericarditis?

Answer 27

``` Cardiac enzymes Inflamation markers (CRP, ESR, WBCs) Thyroid fxn studies Renal fxn studies Body fluid cultures TB skin test ```

Question 28

What is constrictive pericarditis?

Answer 28

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

Question 29

Pathophysiology of constrictive pericarditis

Answer 29

Early diastolic filling unimpaired Chambers expand and collide with unyielding pericardium which halts further diastolic filling "dip and plateau" or "square root" sign seen on pressure tracing

Question 30

Constrictive pericarditis clinical presentation

Answer 30

Slow, indolent process Unexplained right heart failure - -systemic congestion (edema, ascites, hepatomegaly) - -fatigue - -dyspnea Often misdiagnosed as cirrhosis

Question 31

Physical findings with constrictive pericarditis

Answer 31

Elevated JVP with prominent X and Y descents ---(notice this is different than with tamponade) Kussmaul's sign Pericardial knock Systemic congestion ---hepatometgaly, ascites, edema

Question 32

What is Kussmaul's sign?

Answer 32

Lack of an inspiratory decline in JVP

Question 33

What are the differences in patterns in jugular venous pressures in tamponade and constriction?

Answer 33

tamponade - loss of y descent constriction - prominent x and y descents

Question 34

When is the pericardial knock heart?

Answer 34

After S2 | During diastole

Question 35

What do we seen on a pressure tracing of all chambers when someone has constrictive pericarditis?

Answer 35

Equalization of diastolic pressures

Question 36

Chronic pericarditis can lead to what CXR findings?

Answer 36

calcification

Question 37

Constrictive pericarditis therapy

Answer 37

Diuretics | Pericardial stripping