Pericarditis

Question 1

Pericarditis

Answer 1

-Inflamation of pericardium
-May contain exudates, adhesions, blood, or serous type fluid.
-Often not apparent clinically
-Mortality in untreated purulent pericarditis is nearly 100%

Question 2

Fibrinous Pericarditis

Answer 2

Caused by: Dressler’s syndrome (delayed pericarditis 2-10 wks after mi due to antibodies. Responds well to corticosteroids), Uremia or Radiation
-Hear loud friction rub
-"Bread and butter" appearance

Question 3

Serous Pericarditis

Answer 3

-From noninfectious inflammatory diseases:
Rheumatic fever, SLE,
Viral infections (often coxsackie)

Question 4

Suppurative/Purulent Pericarditis

Answer 4

Caused by bacterial, fungal and parasitic infectious agents

Question 5

Most common form is

Answer 5

idiopathic, presumed to be viral (if they can’t pinpoint what’s causing it)

Question 6

Symptoms

Answer 6

**Chest pain**
Most common symptom
Substernal
Sharp, stabbing, burning, pressing
SOB--especially if pericardial effusion
May radiate to back, neck, shoulder, arm
**Pain referral to left trapezius ridge** (upper back/top of shoulder)

Question 7

What is pain from pericarditis referred to left trapezius ridge

Answer 7

Inflammation of the joining diaphragmatic pleura!!!

Question 8

Key symptoms in history

Answer 8

*Chest pain worse when supine (laying down), with inspiration (pleuritic), swallowing (dysphasia) 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.

Question 9

Other S/S

Answer 9

-Fever; usually low grade
-Pericardial friction rub
-Dyspnea; chest pain worse with inspiration
-Dysphagia; irritation of esophagus
-Tachypnea
-Tachycardia
**Beck’s triad** ON TEST
Hypotension, JVD, muffled heart sounds
cardiac tamponade

Question 10

What is Beck's Triad

Answer 10

Hypotension, JVD, muffled heart sounds

(cardiac tamponade)

Question 11

Drug induced causes

Answer 11

Procainamide, hydralazine, isoniazid (INH)

Question 12

Other causes

Answer 12

-Malignancy
-Radiation therapy induced
-Uremia/renal failure
-Acute stemi
**Post myocardial infarction (dressler syndrome)**
-Autoimmune, rheumatic (SLE, RA, scleroderma, sacrcoidosis)
-Fungal (Histoplasmosis,
coccidiomycosis)
-Tuberculosis
-Hypothyroidism
-Cholesterol

Question 13

Bacterial causes

Answer 13

**Staphylococcus most common**
-Streptococcus
-pneumococcus
-Neisseria
-Legionella
-Lyme disease
-Via direct pulmonary extension, endocarditis, penetrating injury, hematogenous spread

Question 14

Viral causes

Answer 14

(VIRAL= most common assumed cause)
**Coxsackie**
-Echovirus
-HIV
-Herpes
-varicella
-Measles, mumps
-EBV
-hepatitis, RSV

Question 15

Most common and important finding is

Answer 15

-Pericardial friction rub
-Best with diaphragm of stethascope
-Lower left sternal border or apex
-Sitting, leaning forward
-Intermittent
-Grating or scratching sound--leather rubbing against leather
-Three components

Question 16

EKG findings for pericarditis (KNOW FOR EXAM!)

Answer 16

-serious of EKGs taken over days/weeks
4 stages observed:
1- ST elevation (Diffuse, seen in almost all leads); *PR depression*
2- Still have PR depression (ST segment elevation has resolved)
3- T wave inversion (diffuse)
4- Normalization

Question 17

Pericardial Effusion

Answer 17

-a complication of pericarditis
-Collection of fluid in the pericardial sac
-Can be so great as to alter cardiac function (e.g., cardiac tamponade)…death
*Acute symptoms with 80ml of fluid
*Chronic build up with collections of 1-2 liters of fluid in sac
-EKG classically described by low voltage (amplitude of QRS are short, SHORT QRS, they don’t look tall) and electrical alternans; caused by pendular motion of beating heart in a large fluid filled sac.

Question 18

Specific EKG findings for pericardial effusion

Answer 18

-Electrical Alternans
-See high amp QRS then low amp QRS (tall, short, tall, short)
***Specific for pericardial effusion!!! NOT specific for pericarditis***

Question 19

Pericardial fat pad sign

Answer 19

-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

Question 20

Test of choice to diagnose pericardial effusion

Answer 20

-Pericarditis is characterized by inflamation of the pericardial layers….this can cause a pericardial effusion

-can find pericardial effusion as a complication; NOT used to diagnose actual pericarditis

Question 21

CXR may show

Answer 21

"Water Bottle Heart"
May see large pericardial effusion

-Can’t diagnose cardiac tamponade (need to use clinical s/s for that)

Question 22

Labs to order

Answer 22

-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 C&S if purulent expected**
-Pericardial biopsy (if no improvement for 3 weeks)

Question 23

Treatment

Answer 23

-If idiopathic or presumed viral use NSAIDs for 1-3 weeks
-Identify/treat cause
-If bacterial, treat > 4 weeks w/ antibiotics
-Pericardiocentesis should be performed

Question 24

Poor prognostic indicators

Answer 24

-Immunosupression
-Myocarditis
-Severe pericardial effusion
-Fever
-NSAID failure
-Trauma
-Oral anticoagulation

Question 25

Constrictive pericarditis is

Answer 25

-A possible result of pericardial injury
-Fibrous thickening of pericardium
-Thickened noncompliant pericardial sac
-Slowly progressive
-Usually specific cause not determined

*Definition: when such fibrous response results in a decrease in passive diastolic filling of the normally distensible cardiac chambers

Question 26

Constrictive pericarditis most commonly results from

Answer 26

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

Question 27

S/S of constrictive pericarditis

Answer 27

**Dyspnea, worsening with exertion!!!
-Chest pain, 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)
-heard during diastole
-The RA is pouring into RV, but due to poor RV compliance, there is no RV expansion.

Question 28

Cardiac tamponade is

Answer 28

compression of heart by fluid in pericardium—blood, effusion, etc

-Equilibration of diastolic pressures in all 4 chambers (ventricles wont fill, atria wont empty, etc, very dangerous)

Question 29

Cardiac tamponade leads to

Answer 29

-Decreased CO
-Becks triad (low bp, distended neck veins, distant heart sounds)
-Tachycardia

Question 30

Cardiac tamponade is a complication of

Answer 30

**pericardial effusion (NOT a complication of pericarditis)**

Question 31

A sign of cardiac tamponade is

Answer 31

Pulsus paradoxus: decreased SBP by 10 mmHg during inspiration

(also seen in: asthma, obstructive sleep apnea, pericarditis, croup)