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Flashcards in pericarditis Deck (40):
1

pericardium

Two layers
Visceral (overlying epicardium)
Parietal (Dense fibrous outer layer)
Pericardial sac holds about 15-50ml

2

pericarditis

Inflamation of pericardium
May contain exudates, adhesions, blood, or serous type fluid.
Often not apparent clinically
*Mortality in untreated purulent pericarditis is nearly 100%* (but not majority of cases)

3

fibrinous pericarditis

Caused by:
-*Dressler’s syndrome*:
Delayed pericarditis 2-10 wks after mi due to antibodies.
Responds well to *corticosteroids*
-Uremia
-Radiation
Loud friction rub, “bread and butter” appearance

4

serous pericarditis

Noninfectious inflammatory disease:
Rheumatic fever
SLE
Viral infections (often *coxsackie*)

5

suppurative/purulent pericarditis

Caused by bacterial, fungal and parasitic infectious agents

6

pericarditis etiology

viral or idiopathic (most common) mortality is practically nonexistent. (There is also no distinguishing clinical features between these two; idiopathic, presumed viral)

More common in men
More common in adults

7

peri Most common symptom

*Chest pain*: SubsternalSharp, stabbing, burning, pressing
SOB--especially if pericardial effusion
May radiate to back, neck, shoulder, arm

*Pain referral to LEFT trapezius ridge quite specific!! Why do you think this is?? Inflammation of the joining diaphragmatic pleura!!!

8

key symptom in hx

(pleuritic) Chest pain worse when supine, with inspiration, swallowing (*dysphagia*) and with body motion
-Chest pain better sitting up, leaning forward
-This helps sometimes to distinguish angina from pericarditis…in that angina does not change with position
H/P paramount in diagnosis

9

Other symptoms and findings

Fever; usually low grade
Pericardial friction rub (almost pathognomonic)
Dyspnea; chest pain worse with inspiration (pleuritic: ddx: PE)
Dysphagia; irritation of esophagus
Tachypnea
Tachycardia
Beck’s triad

10

*Beck's triad* test question

Hypotension, JVD, muffled heart sounds
cardiac tamponade

11

pericarditis causes

Idiopathic--accounts for most cases—assumed viral
Malignancy
Drug induced
Radiation therapy induced
Uremia/renal failure
Acute STEMI
*Post MI (dressler syndrome)*
Auto-immune, rheumatic (SLE, RA, scleroderma, sacrcoidosis)

12

Drug induced pericarditis

Procainamide, hydralazine, isoniazid (INH)

seizure think INH OD

13

*Bacterial causes*

*staphylococcus most common* (on test)
Streptococcus
pneumococcus
Neisseria
Legionella
Lyme disease

Via direct pulmonary extension, endocarditis, penetrating injury, hematogenous spread

14

viral causes

*most common assumed cause*
*Coxsackie*
Echovirus
HIV
Herpes
varicella
Measles, mumps
EBV
hepatitis, RSV

15

more causes

Fungal:
Histoplasmosis
Coccidiomycosis

TB
Hypothyroidism
cholesterol

16

Pericardial friction rub

*Most common and important physical finding*
Best with diaphragm of stethoscope,Lower left sternal border or apex
Sitting, leaning forward
Intermittent
Grating or scratching sound--leather rubbing against leather
Three components

17

EKG dx

Serial ekgs over a period of days/weeks
Four stages (KNOW)

18

EKG stage 1

*ST segment elevation*/acute phase
-Subepicardial injury/inflamation
*Diffuse* ST elevation (multiple leads, not just 1 anatomical area) smiley face, notch
*PR depression*

19

EKG stage 2

ST segments start returning to normal
T-wave amplitude decreases in height
(may still have PR depression)

20

EKG stage 3

T-wave inversions appear
Normal ST segments now present

21

EKG stage 4

normalization

22

ST elevation may be ??

benign, esp. in young ppl

early repolarization

STEMIs don't usually have concavity (smiley face) (more convex)

also small notch before elevation in early repol, not STEMI

23

complication: pericardial effusion (does not have to be due to pericarditis, and not all pericarditis pts have pericardial effusion)

Collection of fluid in the pericardial sac
-Can be so great as to hamper cardiac function (e.g., cardiac tamponade)…death
-Acute symptoms with *80ml of fluid-->symptomatic*
Chronic build up with collections of *1-2 liters* of fluid in sac (pop bottle!)
-EKG classically described by *low voltage (short amplitude QRS-has to transfuse thru fluid) and electrical alternans*; caused by pendular motion of beating heart in a large fluid filled sac.

24

electrical alternans

-alternating QRS amplitude/axis
-low voltage QRS (also for obese pts)
-specific to pericardial effusion

25

pericarditis CXR

Limited value
-May be of normal size--even in setting of pericardial effusion or tamponade
If previous cxr available for comparison, may see an interval enlargement of heart size between the two

26

Pericardial fat pad sign

Seen on lateral CXR
Epicardial fat allows the silhouette of two layers of pericardium to appear separate from the heart
-Pericardial effusion; Sometimes pericarditis
Not commonly seen (typ. get AP not lateral view)

27

*cardiac ECHO*

will help immensely

Cardiac echo can easily diagnose a *pericardial effusion (test of choice)*

Pericarditis is characterized by inflammation of the pericardial layers….this can cause a pericardial effusion
(so will see effusion on ECHO, not pericarditis)

28

CT scan slide 39

pericardial effusion, fluid left back of lung: also have pleural effusion (possibly malignant, blood, pus)

29

CXR

"water bottle" (jug?) heart (like a flask)

cannot dx on this, pericardial effusion is a clinical dx

30

pericardiocentesis

insert needle at 45 degree angle below xiphoid process

put metal EKG lead on needle, will get spike when hit pericardium

31

pericarditis labs
(looking for the etiology)

CBC: may reveal elevated WBC or leukemia
Chem: may reveal uremia
Streptococcal serologic tests: In pts with hx of rheumatic heard disease or pharyngitis
Blood cultures/viral cultures
UA, UDS
Tb,hiv
ESR (sed rate)
Thyroid tests (TSH)
Rheumatologic studies (ana, rf, etc.)
Cardiac markers (troponin, cpk-mb)
**pericardiocentesis for Cx/Sn if purulent expected


32

do Pericardial biopsy…if no ??

improvement for 3 weeks

33

pericarditis tx

If idiopathic or presumed viral: NSAIDS 1-3 weeks (motrin)
Identify/treat cause

If bacterial, treat > 4 weeks antibiotics. Also, pericardiocentesis should be performed.

34

poor px indicators

Immunosupression
Myocarditis
Severe pericardial effusion
Fever
Nsaid failure
Trauma
Oral anticoagulation (more blood around heart)

35

Constrictive pericarditis

A possible result of pericardial injury, post trauma, post op
-Fibrous thickening of pericardium, Thickened noncompliant pericardial sac
-Slowly progressive, Usually specific cause not determined
-Defined “…when such fibrous response results in a decrease in passive diastolic filling of the normally distensible cardiac chambers…”

36

contrictive pericarditis Most commonly results from: ??

Cardiac trauma/intrapericardial bleeding
-Open heart surgery
-Idiopathic, Fungal, tb (in developing world), viral (in developed world), uremic

37

Constrictive pericarditis s/s

Dyspnea, worsening with exertion!!!
CP, PND, orthopnea, B/L LE edema, JVD

Pericardial knock:
After 2nd heard sound.
Due to accelerated RV inflow, followed by abrupt slowing of ventricular expansion:
Diastole
The RA is pouring into RV, but due to poor RV compliance, there is no RV expansion.

38

cardiac tamponade (boards)

Compression of heart by fluid in pericardium—blood, *pericardial effusion*, etc.
-Leads to *decreased CO*
-Equilibration of diastolic pressures in all 4 chambers (bad! no reason for ventricles to fill)
*Becks triad (low bp, distended neck veins, distant heart sounds)
tachycardia

39

cardiac tamponade: Pulsus paradoxus:

decreased SBP by 10 mmHg during inspiration--
also seen in:
asthma
obstructive sleep apnea
pericarditis
croup

40

myocarditis FYI

Inflammation of heart MUSCLE
May be a secondary to a primary infection, e.g., pericarditis
-Viral: *Coxsackie B*, adenovirus, echovirus, influenza, EBV, HIV
-Bacterial: *corynebacterium diphtheriae*, Lyme dz, B-hemolytic strep (rheumatic fever), mycoplasma pneumonia, neisseria meningitidis,
-*1/3 develop to DCM