Met 2: Cardio; Lec. 7 Pericarditis

Front 1

What are the two layers of the pericardium and what separates them?

Back 1

Inner – Visceral pericardium

Outer – parietal pericardium 

Separated by 15 - 50cc of fluid

Front 2

What are the 3 primary functions of the pericardium?

Back 2

1) Fixes heart within mediastinum

2) Prevents extreme dilatation of the heart

3) ?Barrier to spread infection from lungs

Front 3

Name some common causes of acute pericarditis.

Back 3

Infectious -Viruses (most common), bacteria
Non-infectious - post OHS (open heart surgery), post MI, ureamia, cancer (breast and lung mets), rheumatologic disease, drug induced

Front 4

What are the four pathologies of acute pericarditis? Which is the most common? Which suggests malignancy?

Back 4

1) Serous pericarditis = scant WBCs, thin fluid likely clear or straw coloured

2) Serofibrinous = most common. Exudate contains plasma proteins. Portions of pericardium can become thick and fused.
 
3) Suppurative = purulent (uncommon – bacterial infection)

4) Hemmorhagic = grossly bloody (malignancy or TB)

Front 5

What are the common clinical features of pericarditis?

Back 5

Hx: Chest pain (sharp, retrostrenal, radiating to the back), fever, dyspnea

Px: Tachycardia, fever, triphasic pericardial friction rub

Front 6

In a case of pericarditis what diagnostic tests would you order and what would they show?

Back 6

ECG - Diffuse ST elevation, PR depression

BW - increased WBCs, elevated ESR (> 80), mildly elevated troponins

CXR - Normal unless effusion

Echo - Normal, but may show fluid

Front 7

What is the treatment for acute pericarditis?

Back 7

Rest and anti-inflammatory drugs.

Viral pericarditis (most common) usually runs it's course within 1-3 weeks.

Front 8

What is pericardial effusion? What determines whether it will remain silent?

Back 8

An excess buildup of fluid (> 50cc) in the pericardium.

The 3 factors that determine whether or not it remains silent are:
1) The volume of fluid
2) The rate of accumulation
3) The compliance of the pericardium (balloon analogy)

Front 9

What are the clinical features of pericardial effusion?

Back 9

Hx: Chest ache, dyspnea, dysphagia, hoarseness, hiccups

Px: Soft heart sounds (due to fluid insulation), Ewart sign (dullness over posterior left lung)

Front 10

In a case of pericardial effusion what diagnostic tests would you order and what would they show?

Back 10

CXR: Normal until ~250cc of fluid, enlrged cardiac silhouette

ECG: Reduced voltage, electrical alternans (complex variations in the wave size, due to movement of the heart within the fluid filled cavity)

Echo: Fluid, effusion, hemodynamic compromise

BW: WBCs, ESR, troponin, TSH, LFTs, albumin

Pericardiocentesis: Diagnostic and therapeutic

Front 11

What is cardiac tamponade and what may lead to it?

Back 11

Compression of the heart due to an accumulation of fluid due to percarditis a pericardial effusion, blunt chest trauma, ruptured LV following an MI and aortic dissection.

This can result in hypotensive shock and death

Front 12

What is the pathophysiology (consequences) of cardiac tamponade?

Back 12

Ventricles are compressed due to fluid, especially during diastole, when the cardiac pressure is the lowest.

Systemic and pulmonary venous pressures rise. JVP becomes elevated and dyspnea and pulmonary congestion occur as a result.

Reduced filling leads to a decreased CO which leads to hypotensive shock and death.

Front 13

What are the clinical features of cardiac tamponade?

Back 13

Hx: Light-­headedness, dyspnea, tachypnea

Px: Elevated JVP, systemic hypotension, quiet heart sounds, tachycardia, pulsus paradoxus

Front 14

What is pulsus paradoxus, what causes it and in what condition is it seen?

Back 14

It is a decrease in systolic blood pressure by more than 10 mmHg during normal inspiration.

The external compression causes the two ventricles to have a fixed volume. When you breathe in, there is an increased RV volume so the septum shifts left, decreasing LV output.

Seen most commonly in cardiac tamponade.

Front 15

In a case of cardiac tamponade what diagnostic tests would you order and what would they show?

Back 15

Echo: effusion, diastolic chamber collapse

Front 16

How is cardiac tamponade treated?

Back 16

Pericardiocentesis - urgently

Front 17

What is the pathophysiology of constrictive pericarditis?

Back 17

The pericardium becomes thickened and calcified, often "sticking" to the heart.

As a result, diastolic filling is hindered (systole generally unaffected).

On exertion, CO rises to compensate and the pericardium normally dilates to facilitate the increased volume. In constrictive pericarditis, the dilatation is hindered (balloon vs water bottle analogy).

Front 18

What are the clincal features of constrictive pericarditis?

Back 18

Hx: Reduced CO (fatigue, hypotension), elevated systemic venous pressure (JVP, hepatomegaly, ascites, peripheral edema)

Px: Tachycardia, pulsus paradoxus, elevated JVP, pericardial knock on auscultation, Kussmal's sign

Front 19

What is Kussmal's sign, what causes it and in what condition is it seen most commonly?

Back 19

Kussmal's sign is a phenomenon in which the JVP doesn't fall (it actually rises) during inspiration as would be normally expected.

The pericardium is very rigid in constrictive pericarditis, so during inspiration the blood is sucked into the chest, but is not able to get into the heart. This results in more blood flow into the veins, elevating JVP with inspiration. 

It is seen most commonly in constrictive pericarditis.

Front 20

In a case of constrictive pericarditis, what diagnostic tests would you order and what would they show?

Back 20

CXR: May show calcifications

ECG: sinus tachycardia, ST T wave abnormalities, atrial arrhythmias

Echo: Dilated IVC, septal bounce

Cardiac catheterization: Dip and plateau

Front 21

What is the treatment for constrictive pericarditis?

Back 21

1) Surgical removal of the pericardium (pericardiectomy)

2) Waffle procedure - hash marks to relieve some pressure, much like a mango at a buffet