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Flashcards in Pericarditis Deck (31)
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1

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%

2

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

3

Serous Pericarditis

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

4

Suppurative/Purulent Pericarditis

Caused by bacterial, fungal and parasitic infectious agents

5

Most common form is

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

6

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)

7

What is pain from pericarditis referred to left trapezius ridge

Inflammation of the joining diaphragmatic pleura!!!

8

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.

9

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

10

What is Beck's Triad

Hypotension, JVD, muffled heart sounds

(cardiac tamponade)

11

Drug induced causes

Procainamide, hydralazine, isoniazid (INH)

12

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

13

Bacterial causes

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

14

Viral causes

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

15

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

16

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

17

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.

18

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***

19

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

20

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

21

CXR may show

"Water Bottle Heart"
May see large pericardial effusion

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

22

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)

23

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

24

Poor prognostic indicators

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

25

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

26

Constrictive pericarditis most commonly results from

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

27

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.

28

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)

29

Cardiac tamponade leads to

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

30

Cardiac tamponade is a complication of

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