Large Group 5-Pericardial Disease

Front 1

A 28 year old Asian woman comes to emergency department with a history of fever, fatigue and 5 lb. weight loss over the past few months.
She noticed increasing pain in her arms when she has to brush her hair and while doing house work. She also notes pain in her legs while walking.
Physical examination showed a slender Asian woman who is afebrile with HR 90bpm, BP 110/70 in left arm. A bruit is heard on the left carotid artery. There are slightly diminished pulses in her lower extremities.

Back 1

takayasu arteritis

Front 2

describe the histology of takayasu arteritis

Back 2

1. Necrotizing aortitis involving mainly the media.
2. The adventitia is fibrotic and shows endarteritis obliterans.
3. There is mild intimal fibrosis.

Front 3

chronic inflammatory disease of large arteries which progressively develop stenosis, occlusion or aneurysmal degeneration

Back 3

takayasu arteritis

Front 4

what is the gold standard diagnostic tool of takayasu arteritis?

Back 4

angiography

Front 5

what is the diagnostic criteria of takayasu arteritis?

Back 5

age <40
claudication of extremities
decreased pulsation of 1 or both brachial arteries (pulseless disease)
difference of >10 in systolic pressure between arms
bruit over subclavian arteries or abdominal aorta
Arteriographic studies showing narrowing or occlusion of aorta, its primary branches, or large arteries in the proximal upper or lower extremities

Front 6

What is the treatment of Takayasu arteritis?

Back 6

1. corticosteroids
2. Other immunosuppressive drugs are frequently needed.
3. Anti-platelets agents, statins and antihypertensive drugs are frequently considered
4. Surgical management also is equally important when severe obstruction of vessels occurs

Front 7

A 21-yr-old man was found to have a BP reading of 160/95mmHg during an insurance examination. He came to your office for management of HTN.
He feels fine, does not take any other medications and does not smoke. His BP reading is 162/98mmHg in upper extremities. Femoral pulses are diminished bilaterally.
On further exam he is found to have a BP of 128/78mmHg in his lower extremities.
Laboratory tests are unremarkable.

Back 7

Coarctation of the aorta

Front 8

What causes the rib notching seen on the chest x-ray in coarctation of the aorta?

Back 8

dilated intercostal vessels

Front 9

What is coarctation of the aorta?

Back 9

aorta is narrowed; blood is shunted through the left subclavian artery through the intercostal arteries

Front 10

Why are the femoral pulses decreased in coarctation of the aorta?

Back 10

they are distal to the narrowing of the aorta

Front 11

What effects does coarctation of the aorta have on the heart?

Back 11

Because of the obstruction to flow in the Aorta the pressure in the ascending aorta is high. This increases afterload to the LV.
This causes LV Hypertrophy
This may in turn cause LA hypertrophy with increased LA pressure.
The PV pressure increases and then RV pressure increases and then RVH.

Front 12

A 65-year-old man with poorly controlled hypertension for 15 years is brought to the emergency department for sudden-onset of severe back pain that is described as, “tearing, sharp pain” His BP is 86/45, P 130

Back 12

aortic dissection

Front 13

What is a characteristic of aortic dissection on chest x-ray?

Back 13

mediastinal widening (>8cm)

Front 14

What is the management of aortic dissection?

Back 14

Any ascending aortic dissection needs surgery and medical management to prevent recurrence.
Descending aortic dissections may be managed medically or may require surgery.

Front 15

A 63-year-old woman with hypertension and metastatic lung carcinoma presents with increasing respiratory distress.
Physical exam reveals a BP of 85/40 mmHg and pulse of 110bpm with jugular venous distension.
Heart sounds are distant.

Back 15

cardiac tamponade

Front 16

What is Beck's triad?

Back 16

3 features characteristic of cardiac tamponade:
1. Decline in systemic arterial pressure
2. Elevation in systemic venous pressure (e.g. distended neck vein)
3. A small, quiet heart

Front 17

What is electrical alternans?

Back 17

This is seen on EKG characteristic of cardiac tamponade:
Alternating amplitude of the QRS on EKG
Produced by heart swinging motion in pericardium

Front 18

What is pulsus paradoxus?

Back 18

An exaggerated drop in SBP with inspiration (>10mmHg)

Front 19

What are the treatment options of cardiac tamponade?

Back 19

non-surgical: pericardiocentesis; balloon pericardiotomy
surgical

Front 20

What is pericardiocentesis used for?

Back 20

Diagnostic tap-usually not indicated; rarely have positive cytology or infection that can be diagnosed.
Therapeutic drainage-indicated for significant elevation of the central venous pressure.

Front 21

What are the benefits of an echo-guided pericardiocentesis?

Back 21

SAFE and EFFECTIVE
locating the optimal site of puncture
determining the depth of the pericardial effusion and the distance form the puncture site to the effusion
monitoring the results of the pericardiocentesis

Front 22

What are the surgical options in the treatment of cardiac tamponade?

Back 22

Creating a pericardial window by:
Balloon dilatation of a needle pericardiostomy
subxyphoid surgical pericardiostomy
video-assisted thoracoscopy with localized pericardial resection
anterolateral thoracotomy with parietal pericardial resection

Front 23

A 40-year-old man develops severe substernal chest pain that is sharp, constant and unrelieved by rest.
The pain is aggravated by deep breathing.
The pain radiates to both arms.

Back 23

acute pericarditis (most likely viral)

Front 24

What is the work up for acute pericarditis?

Back 24

More history and find any relavant conditions causing pericarditis.
EKG, Chest X-ray, CBC
Echocardiogram
Work up to determine the etiology of the pericarditis including skin tests to r/o TB if appropriate.
Viral titers (acute phase and a few weeks later)

Front 25

What is the treatment for acue pericarditis?

Back 25

Treat underlying cause
Analgesic agents: codeine
Anti-inflammatory agents: ASA; NSAID (indomethacin)
Corticosteroids are symptomatically effective, but preferably avoided.

Front 26

What is chronic relapsing pericarditis?

Back 26

occurs in a small % of patients with acute idiopathic pericarditis
steroid dependency requiring gradual tapering over 3-12 months; NSAIDs, analgesics, and colchicine may be beneficial
pericardiectomy for relief of symptoms is not always effective

Front 27

describe the anatomy of the pericardium

Back 27

serosa (visceral pericardium)-mesothelial monolayer facilitates ion and fluid exchange
fibrosa (parietal pericardium)-fibrocollagenous tissue
pericardial fluid-clear plasma ultrafiltrate
ligamentous atachments-sternum, vertebral column, diaphragm

Front 28

What is the purpose of the pericardium?

Back 28

Not needed to sustain life.
Physiologic functions:
limit cardiac dilatation.
limit cardiac displacement.
maintain normal ventricular compliance.
reduce friction to cardiac movement.
barrier to inflammation.
In cases of congenital absence of pericardium heart can move easily and get twisted.

Front 29

What's the pathogenesis of pericardial inflammation?

Back 29

Types of spread:
Contiguous spread
Hematogenous spread-septicemia, toxins, neoplasm, metabolic
Lymphangetic spread
Traumatic or irradiation
Pathology:
inflammation provokes a fibrinous exudate; normal transparent and glistening pericardium is turned into a dull, opaque, and “sandy” sac; can cause pericardial scarring with adhesions and fibrosis.

Front 30

What is constrictive pericarditis?

Back 30

fibrosis and adhesion of pericardial layers; limits distensibility
cause of diastolic heart failure
pericardial calcifications and pleural effusions show up on chest x-ray