Cv 15: Pericardial Diseases

Front 1

What are the layers of the pericardium?

Back 1

- Visceral
- Parietal

Front 2

What is the histological organization of the Visceral Pericardium? Function?

Back 2

- Membrane composed of single layer of mesothelial cells
- Adheres to epicardial surface of heart

Front 3

What is the histological organization of the Parietal Pericardium? Function?

Back 3

- Fibrous layer 2 mm in thickness, containing collagen and elastic fibers
- Collagen contains wavy bundles (low level of stretch) and Streight bundles (high levels of stretch)

Front 4

What is the relationship between the visceral and parietal pericardium?

Back 4

- Visceral pericardium reflects back near the origin of the great vessels and becomes the parietal pericardium
- Space contains 50 mL serous fluid

Front 5

What parts of the heart are extra-pericardial?

Back 5

Part of posterior wall of LA

Front 6

What structures stabilize the pericardium?

Back 6

- Diaphragm
- Sternum
- Spine

Front 7

What nerve is enveloped by the parietal pericardium?

Back 7

Phrenic nerves

Front 8

What can happen when the phrenic nerve is irritated?

Back 8

Hiccups

Front 9

What causes hiccups?

Back 9

Irritation of phrenic nerve

Front 10

What are the functions of the Pericardium?

Back 10

- Maintains heart position
- Lubricates visceral and parietal layers
- Barrier to infection
- Prostaglandin secretion (modulates coronary vascular tone)
- Restraining effect on cardiac volume (small reserve volume)

Front 11

What does the pericardium secrete? Function?

Back 11

Prostaglandins - modulates coronary vascular tone

Front 12

How does the pericardium affect the cardiac volume?

Back 12

Restraining effect on cardiac volume:
- Mechanical properties of pericardial tissue
- Small reserve volume
- Tensile strength similar to rubber

Front 13

How does the stretchability of the pericardium depend on the cardiac volume? Implications?

Back 13

- Normal cardiac volume: more elastic - stretches easily
- Increased cardiac volume: pericardium becomes stiff - resistant to further stretch

*In a pericardial effusion, once critical volume of effusion is reached, small additional amounts lead to a large increase in intra-pericardial pressure
- Removal of a small amount of fluid leads to significant improvements of pressure

Front 14

How does the pericardium adapt to cardiac dilatation?

Back 14

- Acutely, increasing volume can lead to significant increases in pressure

- Chronically, leads to adaptations to accommodate increased volume; pericardial growth occurs in response to chronic stretch
- PV curve shifts to the R w/ decreased slope (less increased P d/t increase V)

Front 15

What are the implications of chronic cardiac dilation?

Back 15

- Pericardium grows in response to the chronic stretch
- Slowly accumulating pericardial effusions can become very large before becoming symptomatic (as in hypothyroidism)

Front 16

What can cause a slowly accumulating pericardial effusion?

Back 16

Hypothyroidism

Front 17

What are the causes of acute pericardial inflammation?

Back 17

* Majority (80-90%) are idiopathic
* Most assumed to be viral (routine testing of specific viral agents is not done because of cost and rarely alters management)

- Other infections (bacterial, myobacterial)
- Radiation
- Blunt / penetrating trauma
- CT disorder (SLE, RA, systemic sclerosis)
- Post-MI or Dressler Syndrome

Front 18

What are the characteristic symptoms of Acute Pericarditis?

Back 18

- Chest pain almost always present (moderate to severe intensity)
- Relieved when sitting down, worse when lying down
- Sharp, pleuritic pain
- Substernal, epigastric, L chest, trapezius muscle area (specific for pericarditis)

Front 19

What are the possible differential diagnoses for chest pain that is felt in Acute Pericarditis?

Back 19

– Pneumonia with pleurisy (Pleuro-pericarditis) – PE with infarction
– Costochondritis
– GERD
– Intraabdominal processes
– Aortic dissection
– Pneumothorax
– Herpes Zoster (before skin lesions)
– Myocardial ischemia/infarction

Front 20

What physical exam findings indicate Acute Pericarditis?

Back 20

- Fever, tachycardia, anxiety (not always present)
- Pericardial friction rub (best heard at L LSB w/ patient leaning forward)

Front 21

What is a "Pericardial Friction Rub" caused by? Physical exam findings?

Back 21

- Cause: contact between parietal and visceral pericardia

- 3 components: ventricular systole, diastole, atrial contraction

- Best heard at L LSB, w/ patient leaning forward
- Dynamic (similar to EKG)
- Disappearing / returning over short periods of time

Front 22

How sources of information do you use to diagnose Acute Pericarditis?

Back 22

- Symptoms (history)
- Exam findings (physical)
- ECG

- Echo not necessary for diagnosis

Front 23

What are the ECG findings associated w/ Acute Pericarditis?

Back 23

Dynamic (like rub)

ST segment elevation
- Diffuse (not in leads aVR, V1)
- Occasionally focal (trauma and post-op)
- ST segment concave
- No reciprocal changes

Upright T waves

*PR depression (elevation in aVR) - may be the only ECG finding

Front 24

What are the differences between ST elevation in STEMI vs Acute Pericarditis?

Back 24

- STEMI: localized ST elevation (not in all leads)
- AP: diffuse presentation (except not present in aVR and V1), ST segment is concave

*AP may have focal ST elevation in post-op or traumatic presentation

Front 25

What are the stages of Pericarditis on EKG?

Back 25

Stages I, II, III, IV

Front 26

What are the features of Stage I?

Back 26

- Diffuse, concave ST-segment elevation
- Early on ST elevation may be focal and mimic AMI

Front 27

What are the features of Stage II?

Back 27

- ST segments normalize, w/ J point returning to baseline
- T-wave amplitude begins to decrease
- PR depression (which may make it appear as though there is continued ST elevation)

Front 28

What are the features of Stage III?

Back 28

- T wave inversions develop diffusely (may be quite deep)
- No PR depression or ST elevation

Front 29

What are the features of Stage IV?

Back 29

- EKG abnormalities again normalize
- T-wave inversions may become permanent

Front 30

What does this EKG represent? Features?

Back 30

Stage I of Pericarditis
- Diffuse, concave ST-segment elevation
- Early on ST elevation may be focal and mimic AMI

Front 31

What does this EKG represent? Features?

Back 31

Stage II of Pericarditis
- ST segments normalize, w/ J point returning to baseline
- T-wave amplitude begins to decrease
- PR depression (which may make it appear as though there is continued ST elevation)

Front 32

What does this EKG represent? Features?

Back 32

Stage III of Pericarditis
- T wave inversions develop diffusely (may be quite deep)
- No PR depression or ST elevation

Front 33

What does this EKG represent? Features?

Back 33

Stage IV of Pericarditis
- EKG abnormalities again normalize
- T-wave inversions may become permanent

Front 34

What are "electrical alternans"? Cause?

Back 34

- Alternation between large and small QRS complexes
- Sign of pericardial effusion

Front 35

What are the lab findings for Acute Pericarditis?

Back 35

Idiopathic "Viral" Pericarditis (rather non-specific)
- Mildly elevated WBC count w/ lymphocytes
- Mildly elevated ESR

Front 36

What are some secondary causes of the lab findings of acute pericarditis?
- Mildly elevated WBC count w/ lymphocytes
- Mildly elevated ESR

Back 36

- Significant WBC elevation w/ left shift
- Anemia, elevated ESR (CT disorder)
- Elevated ESR (CT disorder, TB)

Front 37

How do chest x-ray findings affect your diagnosis of Acute Pericarditis?

Back 37

- Usually normal in uncomplicated pericarditis
- Abnormal CXR finding considered secondary disorders (pleural effusions, infiltrates, mass lesions, CHF)

Front 38

How do Echo results affect your diagnosis of Acute Pericarditis?

Back 38

- Not required for diagnosis and management of idiopathic pericarditis
- Small, otherwise clinically silent, effusion not uncommon
- Large effusion considered secondary disorder

Front 39

Is a large effusion expected for Acute Pericarditis?

Back 39

- No - this is probably a secondary disorder (secondary pericarditis)
- However, a small, clinically silent effusion, is not uncommon for primary pericarditis

Front 40

How should you treat Acute Pericarditis?

Back 40

Acute idiopathic "viral" pericarditis:
- Uneventful recovery in 70-90%
- Treat w/ NSAIDs (post MI, use Aspirin)
** Best: Treat w/ Colchine (w/ NSAIDs or as alternative to NSAIDs)
- Treat w/ Steroids

Secondary Pericarditis
- Identify and treat secondary disorder

Front 41

What are the pros and cons of using Colchicine for Acute Idiopathic ("Viral") Pericarditis?

Back 41

Pros:
- Decreased incidence of recurrent pericarditis
- Anti-inflammatory
- Preferential concentration in leukocytes (16x higher peak conc. than in plasma)

Cons:
- Discontinuation rate 10-15% (d/t GI side effects)

Front 42

What are the pros and cons of using Steroids for Acute Idiopathic ("Viral") Pericarditis?

Back 42

- Rapid response to treatment
- May encourage relapses (avoid if possible)

Front 43

Which tx for acute pericarditis decreases relapses? Increases relapses?

Back 43

- Decreased relapses: colchicine
- Increased relapses: steroids

Front 44

What is the mechanism of Colchicine?

Back 44

- Disrupts microtubules / inhibits microtubule self-assembly
- Takes place in mitotic spindle or in interphase stage
* Inhibits movements of intercellular granules and secretion of various substances in leukocytes

Front 45

What were the conclusions of the COPE (Colchicine for acute Pericarditis) trial?

Back 45

- Colchicine + conventional therapy led to a clinically important and statistically significant benefit over conventional therapy alone
- Decreased the recurrence rate by 50%

(Conventional therapy: aspirin, ibuprofen, or glucocorticoids)

Front 46

What criteria are necessary to diagnose Acute Pericarditis?

Back 46

Two of the following:
– Typical chest pain (sharp and pleuritic,
improved by sittng up and leaning forward)
– A pericardial friction rub
– Suggestive changes of on ECG (widespread ST-segment elevation or PR depression)
– New or worsening pericardial effusion

Front 47

What criteria are necessary to diagnose Incessant Pericarditis?

Back 47

Persistent pericarditis w/ symptom-free intervals of less than 6 weeks duration

Front 48

What were the conclusions of the ICAP (Investigation on Colchicine for Acute Pericarditis) trial?

Back 48

When colchicine is added to conventional therapy, it significantly reduced the rate of incessant or recurrent pericarditis

Front 49

What are some non-inflammatory causes of pericardial disease ?

Back 49

- Hydropericardium: accumulation of serous transudate in pericardial space (assoc. w/ CHF, hyponatremia, or chronic kidney or liver disease)

- Hemopericardium: accumulation of blood in pericardial sac (assoc. w/ trauma of heart or aorta; or myocardial rupture after acute MI)

Front 50

What happens in Hydropericardium? What is it associated with?

Back 50

- Accumulation of serous transudate in pericardial space
- Assoc. w/ CHF, hyponatremia, or chronic kidney or liver disease

Front 51

What happens in Hemopericardium? What is it associated with?

Back 51

- Accumulation of blood in pericardial sac
- Assoc. w/ trauma of heart or aorta; or myocardial rupture after acute MI

Front 52

What is the most common cardiac manifestation of HIV infection?

Back 52

Pericardial Effusion - most are small, asymptomatic, and idiopathic

Front 53

What is the relationship between HIV and Pericardial disease?

Back 53

- 20% of HV patients develop pericardial involvement
- More common pre-HAART
- Pericardial effusion is the most common cardiac manifestation of HIV infection
- Seen in more advanced stages of disease (greater mortality risk)
- Most effusions are small, asymptomatic, and idiopathic

Front 54

What can cause large effusions in HIV patients?

Back 54

- Infection (MT, MAI, CMV, Cryptococcus)
- Neoplasm (Kaposi Sarcoma, Lymphomas)

Front 55

How do you treat pericardial effusions in HIV patients?

Back 55

Treat underlying cause

Front 56

If you have a patient presenting w/ ST elevation on EKG, what should you do?

Back 56

Send them to the cath lab - it might just be acute pericarditis, but it could be ACS

Front 57

What is Pulsus Paradoxicus?

Back 57

Variation of systolic pressure by >10 mmHg (consistent w/ pericardial effusion)