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49 Cards in this Set
- Front
- Back
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Definition of:
- Pericardium - Visceral Pericardium - Parietal Pericardium |
PERICARDIUM
sac surrounding heart and proximal portions of great vessels VISCERAL PERICARDIUM (epicardium) single layer of mesothelial cells; closely adherent to myocardium PARIETAL PERICARDIUM outer layer of sac; inner lining of mesothelial cells with outer fibbrocollagenous elastic layer **Serous pericardial fluid btwn the 2 layers |
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Pericardial Fluid
- description - location - amount |
serous fluid between visceral and parietal layers
- 5-35 ml (small amount) |
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Functions of the pericardium
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- limit overall cardiac motion within chest
- restrict filling of heart and limit acute dilatation - contribute to resting diastolic pressures within chamber (R > L) - pericardial fluid is lubricant and protectorant |
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Acute Pericarditis - definition
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inflammatory reaction in pericardium due to any of multiple insults...
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Causes of Acute Pericarditis
- majority of cases due to...? |
- Idiopathic (majority!!!!!)
- Infectious (HIV, Coxsackie, bact, TB, fungi, etc.) - Autoimmutine (lupus, rheum arth) - Neoplasticc (breast, lung, lymphoma), - MI (acute, Dresslers) - Drug-induced (procainamide, hydralazine) - Traumatic - Uremia - Radiation - Myxedema |
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What are the clinical symptoms of acute pericarditis?
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- Chest pain (pleuritic) - increases with deep breathing, cough, supine position [relief with leaning forward]
- Dyspnea - Pericardial friction rub |
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What are the typical EKG findings of acute pericarditis?
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- ST elevaion (concave up "J wave")
- PR depression - over time, inverted T wave |
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What are the echo findings of acute pericarditis?
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pericardial fluid may or may not be present
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What is the diagnosis of acute pericarditis based on?
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Primarily, the combo of CLINICAL PRESENTATION and ECG
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What is the management for acute pericarditis?
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- address underlying cause
- pain tx (aspirin, NSAIDs, colchicine, steroids) - usually self-limited, but can become recurrent |
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What is a pericardial effusion?
What causes it? |
fluid accumulation within pericardial sac
can occur due to any of the causes of acute pericarditis |
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What are some clinical findings of a pericardial effusion?
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- Often unremarkable, especially when small, and until there is hemodynamic compromise...
- If presses on adjacent structures: ~ dyspagia ~ hiccups (diaphragmatic irritation) ~ dyspnea ~ hoarseness (compressing recurrent laryngeal nerve) - If no hemodynamic compromise: ~ distant heart sounds ~ decrease in intensity/absence of pericardial friction rub ~ Ewart's Sign - dullness to percussion and bronchial breath sounds in L infrascapular area (due to atelectasis and consolidation of L lung due to compression) |
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What determines increased intrapericardial pressure?
How much fluid can accumulate within pericardial sac before there is increased pressure |
- volume of effusion
- rate of accumulation - characteristics of pericardium itself ** up to 2 liters before increase in pressure (as long as accumulation is slow!) |
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What is evidence of Pericardial Effusion on a chest x-ray?
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"water bottle heart"
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What about pericardial effusion can be assessed by echo?
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- presence of fluid
- quantification of fluid - detection of increased intrapericardial pressure - hemodynamic consequence |
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What is the key to diagnosing a pericardial effusion?
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ECHO
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What is Cardiac Tamponade?
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clinical syndrome resulting from increase in intrapericardial pressure due to fluid accumulation
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What are the manifestations of Cardiac Tamponade? What are the resulting symptoms (gradual v. rapid effusion)and physical exam findings?
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Manifests from hemodynamic compromise:
- elevation of intracardiac pressure - progressive limitation on ventricular diastolic filling - reduction in SV and CO Symptoms: ~ Gradually Accumulating: - chest pain - cough - dyspnea - fatigue, weakness, anorexia, weightloss ~ Acute tamponade - hypotension - shock - hypoperfusion of organs and peripheral tissues Physical Exam: - Tachycardia - Tachypnea - Elevated systemic venous pressure (JVD with prominent x descent; absence y descent) - Decreased systolic BP - Exaggerated Pulsus paradoxus - Diminished heart sounds and PMI - Rapid shock, cool extremities, hypoperfusion |
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What is pulsus paradoxus?
What is pulsus paradoxus during cardiac tamponade? |
Inspiratory decrease in systolic pressure and palpable pulse
- due to increase venous return to right heart, but pooling of blood in lungs (lung arteries dilated), so lack of blood going to L heart - exaggerated in tamponade bc fluid pushes on L heart and causes blood to go back into lungs and even less blood is ejected on systole |
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What are the EKG changes in Cardiac Tamponade?
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- nonspecific S-T changes
- low voltage - Electrical Alternans - varied QRS heights throughout, due to swinging of heart in fluid-filled sac |
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What can echo tell you about cardiac tamponade?
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- presence/size of effusion
- signs of increased intracardial pressure - respiratory variations (increased tricuspid flow on inspiration; decreased mitral flow on inspiration) - elevated right-sided pressure |
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What can cardiac cath tell you about cardiac tamponade?
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- increased intrapericardial pressure
- elevated R atrial pressure - big x-descent, abscent y-descent - equalization of R heart diastolic pressures - marked decrease in SV - reduced systemic arterial pressure |
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What are treatments for cardiac tamponade??
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- pericardiocentesis (echo can help guide)
- pericardial window (for particularly malignant or bacterial effusions) |
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What is constrictive pericarditis?
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- Chronic
- Results from fibrosed, adherent, thickened pericardium - Causes restricted diastolic filling --> elevation and equilibrium of diastolic pressures in all 4 cardiac chambers |
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What are the etiologies of constrictive pericarditis?
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Multiple!!!
- Can result from any form of acute pericarditis.... - 55% idiopathic (often from viral pericarditis) - 12% TB (classic cause!! now rare) - Other: post-surgical, mediastinal radiation, chronic renal failure, etc. |
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What are the effects of constrictive pericarditis on diastole?
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Restricted filling of all 4 chambers --> elevation and equilibrium of diastolic pressures
Rapid filling in early diastole --> halted abruptly by rigid pericardium ("dip and plateau" pattern of ventricular filling) |
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What are the main pathophysiologic signs of constrictive pericarditis?
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- restricted diastolic filling
- rapid filling, then abrupt halt - KUSSMAUL'S SIGN - reduction in SV and CO |
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Explain Kussmaul's Sign that occurs with constrictive endocarditis?
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Normal: jugular veins collapse on inspiration bc expand volume of thorax
Const. Pericarditis: - Jugulars stay full - Bc of fluid, intrathoracic pressures not transmitted to intracardiac chambers or pericardial space, so vessels don't "feel" release of pressure - Systemic venous pressure may increase with inspiration |
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What are the physical exam findings for constrictive pericarditis?
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- Diastolic pericardial knock - reflects rapid halt in early filling
- Elevated JVP - rapid collapse of y-descent due to rapid early filling, then halt - Signs of R-sided CHF - edema, acites [**no L-sided CHF] - Hepatic congestion |
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Clinically, what other condition can be most easily confused with constrictive pericarditis?
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Restrictive Cardiomyopathy
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What EKG findings are consistent with constrictive pericarditis?
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- low QRS voltage
- nonspecific t-wave abnorms - a fib in some ppl |
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What can you see via CT or MRI for constrictive pericarditis?
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thickened pericardium
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What does an echo tell you about constrictive pericarditis?
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- pericardial thickening
- abnormal septal motion (due to rapid early ventric filling) - hepatic vein dilation |
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What does cardiac catheterization tell you about constrictive pericarditis?
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- evaluation and equilibrium of diastolic pressures
- early diastolic dip followed by plateau in L and R ventricular pressure tracings - low SV and CO - increased systemic vascular resistance |
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What is the management for constrictive pericarditis?
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- Pericardiectomy - signficant operative mortality
- Progressive deterioration without surgery |
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Regarding cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy...
In which is pulsus paradoxus exaggerated? |
- cardiac tamponade
- (possibly const peri, restrictive CM) |
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Regarding cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy...
In which is Kussmaul's Sign present? |
- constrictive pericarditis
- (possibly restrictive CM) - (NOTTTT card tamponade) |
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Regarding cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy...
In which is the pericardial knock present? |
- constrictive pericarditis
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Regarding cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy...
In which is the pericardial knowck present? |
- cardiac tamponade
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Regarding cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy...
What is the venous waveform pattern in each? |
Cardiac Tamponade:
- Rapid X - Absent Y Constrictive Pericarditis - Rapid X and Y descent Restrictive Cardiomyopathy - Rapid X and Y descent |
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Regarding cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy...
In which are there equal diastolic pressures? |
Cardiac Tamponade and Constrictive Pericarditis have equal diastolic pressures
- (Restrictive Cardiomyopathy: LV > RV) |
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Regarding cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy...
In which is there the "dip and plateu" of diastole? |
- Constrictive Pericarditis - rapid early diastolic filling of ventricles, then abrupt halt
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Regarding cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy...
What is seen on a CT/MRI/echo? |
Cardiac Tamponade:
- pericardial effusion Constrictive pericarditis: - pericardial thickening or calcification Restrictive Cardiomyopathy: - Increased myocardial thickness |
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What percent of cardiac tumors are benign?
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75% - of these, nearly 50% are myxomas
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What are the most common cardiac tumors?
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- Myxoma
- Rhabdomyoma (most common in children) - Papillary Fibroelastoma, lipoma, hemangioma |
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What are the most common primary malignant cardiac tumors?
- clinical course? |
**Most are sarcomas
- 50% = angiosarcoma, rhabdomyosarcoma --> typically have very rapid clinical deterioration leading to death |
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What are the most common secondary malignant cardiac tumors?
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Metastasis of....
- Lymphoma - Renal Cell Carcinoma - Lung Cancer |
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Myxoma
- location/descrip - usually isolated? - genetic?? - nick name? - symptoms - complications - dx - tx |
Location:
- 80% L atrium - Most often attached to Fossa Ovalis - Often pedunculated and mobile - 90% solitary - 10% familial Nickname: "Great Masquerader" bc... Sx are often systemic! - fever, wt loss, dyspnea, syncope, anemia, elevated sedimentation rate - many sx due to secretion of Il-6 (inflammatory cytokine) Complication: embolization of fragments Dx: echo Tx: surgical removal |
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Papillary Fibroelastoma
- location - sx - complication |
- Usually on "downstream" side of valves
- Often asymptomatic (incidental finding) - Potential to embolize |
