Flashcards in Pericarditis Deck (31)
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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%
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Fibrinous Pericarditis
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
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Serous Pericarditis
-From noninfectious inflammatory diseases:
Rheumatic fever, SLE,
Viral infections (often coxsackie)
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Suppurative/Purulent Pericarditis
Caused by bacterial, fungal and parasitic infectious agents
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Most common form is
idiopathic, presumed to be viral (if they can’t pinpoint what’s causing it)
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Symptoms
**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)
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What is pain from pericarditis referred to left trapezius ridge
Inflammation of the joining diaphragmatic pleura!!!
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Key symptoms in history
*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.
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Other S/S
-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
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What is Beck's Triad
Hypotension, JVD, muffled heart sounds
(cardiac tamponade)
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Drug induced causes
Procainamide, hydralazine, isoniazid (INH)
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Other causes
-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
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Bacterial causes
**Staphylococcus most common**
-Streptococcus
-pneumococcus
-Neisseria
-Legionella
-Lyme disease
-Via direct pulmonary extension, endocarditis, penetrating injury, hematogenous spread
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Viral causes
(VIRAL= most common assumed cause)
**Coxsackie**
-Echovirus
-HIV
-Herpes
-varicella
-Measles, mumps
-EBV
-hepatitis, RSV
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Most common and important finding is
-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
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EKG findings for pericarditis (KNOW FOR EXAM!)
-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
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Pericardial Effusion
-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.
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Specific EKG findings for pericardial effusion
-Electrical Alternans
-See high amp QRS then low amp QRS (tall, short, tall, short)
***Specific for pericardial effusion!!! NOT specific for pericarditis***
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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
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Test of choice to diagnose pericardial effusion
-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
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CXR may show
"Water Bottle Heart"
May see large pericardial effusion
-Can’t diagnose cardiac tamponade (need to use clinical s/s for that)
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Labs to order
-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)
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Treatment
-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
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Poor prognostic indicators
-Immunosupression
-Myocarditis
-Severe pericardial effusion
-Fever
-NSAID failure
-Trauma
-Oral anticoagulation
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Constrictive pericarditis is
-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
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Constrictive pericarditis most commonly results from
-Cardiac trauma/intrapericardial bleeding
-Open heart surgery
-Idiopathic, Fungal, tb (in developing world), viral (in developed world), uremic
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S/S of constrictive pericarditis
**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.
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Cardiac tamponade is
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)
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Cardiac tamponade leads to
-Decreased CO
-Becks triad (low bp, distended neck veins, distant heart sounds)
-Tachycardia
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