Pericardial Disease

Front 1

Most common cause of acute pericarditis?

Back 1

idiopathic and viral; used interchangeably

Front 2

Most common virus associated with acute pericarditis?

Back 2

coxsackievirus B

Front 3

What are the other common causes of infective acute pericarditis

Back 3

-bacterial = pneumococcal spread most common

-TB

Front 4

Noninfectious causes of acute pericarditis (8)

Back 4

1. Post MI

2. Uremia

3. Neoplastic disease

4. Radiation-induced

5. connective tissue diseases (SLE + RA)

6. Drug induced

7. Trauma

8. Post pericardiotomy

Front 5

Typical presentation of acute pericarditis in therms of:

1. Quality

2. Quantity

3. Onset

4. Duration

5. Location

6. Radiation

7. Aggravation

8. Alleviation

9. Associated symptoms

Back 5

1. Quality = Sharp pain, pleuritic

2. Quantity = Variable, often severe

3. Onset = Usually insidious

4. Duration = Hours/days

5. Location = restrosternal, precordial

6. Radiation = shoulder

7. Aggravation = breathing, lying down

8. Alleviation = Sitting up, NSAIDs

9. Associated symptoms = viral, constitutional

Front 6

What differentiates it from myocardial ischemia or infarction is that the pain of pericarditis is typically ?

Back 6

"typically sharp, pleuritic (it is aggravated by inspiration and coughing), and positional (e.g., sitting and leaning forward often lessen the discomfort)."

Front 7

Physical exam findings in acute pericarditis

Back 7

1. Tachycardia + often febrile.

2. Pericardial friction rub is pathognomonic
3. Remainder of examination is often normal

Front 8

1. How is the Pericardial friction rub described as sounding?

2. How is it best heard?

Back 8

1. scratching, grating, “velcro” sound
2. best heard with diaphragm, with patient leaning forward

Front 9

How are WBC, CRP, and ESR levels effected in pericarditis

Back 9

All are increased

Front 10

Classic ECG finding in pericarditis?

Back 10

1. ST elevation in all leads with concave-up scooping

2. PR depression in inferior leads

Front 11

What conduction disturbance and ventricular arrhythmias are a feature of pericarditis?

Back 11

Sinus tach is common; other atrial arrhythmias suggest other heart disease

Conduction disturbance, ventricular arrhythmias are not a feature of pericarditis

Front 12

Treatment of pericarditis

Back 12

Rest until pain free

Nonsteroidal anti-inflammatory drugs (NSAID) (indomethacin, ibuprofen, etc.)

Front 13

What is a pericardial tamponade

Back 13

Elevated intrapericardial pressure resulting from accumulation of pericardial fluid and
resulting in:
1. Impairment of ventricular filling
2. Reduction in ventricular stroke volume

3. Diminished cardiac output resulting in
organ hypoperfusion

"A pericardial effusion that has gone bad"

Front 14

Cardiac tamponade should be suspected in any patient with

Back 14

known pericarditis, pericardial effusion, or chest trauma who develops signs and symptoms of systemic vascular congestion and decreased cardiac output

Front 15

Symptoms of pericardial tamponade are often associated with

Back 15

increased sympathetic tone (palpitations, anxiety, etc.)

Front 16

Halmark physical exam finding of pericardial tamponade

Back 16

Becks Triad:
1. hypotension
2. elevated jugular venous pressure (with absent y- descent)
3. quiet precordium (muffled heart sounds)

Front 17

Other physical exam findings of pericardial tamponade

Back 17

1. Tachycardia
2. Increased pulsus paradoxus
3. Increased sympathetic tone

Front 18

What does the pressure tracing of the pericardium normally look like? In tamponade?

Back 18

Front 19

What is Increased pulsus paradoxus

Back 19

Normally the SBP decreases <10mmHg on inspiration due to increased venous return increasing RV size, which decreases LV size b/c of the septum bulging = decreased SV = decreased SBP

In tamponade the decrease is > 10-15mmHg because the space for the RV to expand is smaller, resulting in more of a bulge into the LV

Front 20

ECG findings in pericardial tamponade?

Back 20

1. low voltage, sinus tachycardia

2. electrical alternans (high spec, low sens)

Front 21

Echo findings in pericardial tamponade?

Back 21

1. shows RA or RV diastolic collapse, respiratory variation in transvalvular flow

2. usually a dilated inferior vena cava

Front 22

Treatment of pericardial tamponade

Back 22

1. Administer intravenous fluids and vasopressors (i.e., dopamine) to stabilize BP while awaiting definitive treatment
2. pericardiocentesis
3. Treat underlying disease

Front 23

Mild pericardial constriction symptoms?

Back 23

Related to elevated right heart pressures:

Ascites, edema, hepatic congestion

Front 24

More severe pericardial constriction symptoms?

Back 24

signs of left heart failure appear:

dyspnea, cough, PND, weight loss, fatigue

Front 25

Physical Exam findings of constrictive pericarditis (7)

Back 25

1. Elevated JVP

2. Kussmaul's sign

3. Pericardial knock

4. hepatosplenomegaly

5. ascites

6. edema

7. Pulsus paradoxus

Front 26

Jugular venous waveform changes with constrictive pericarditis compared to tamponade

Back 26

Front 27

Kussumaul sign?

Back 27

Normally deep breath = decreased intrathoracic pressure = increased venous return = volume in R atria increases but CVP falls and Jugular veins collapse

Kussmauls = on inspiration veins dont fall or they can actually increase —> breathing increases venous return but it has nowhere to go so it just engorges the venous system

Front 28

How can the diagnosis of constrictive pericarditis be confirmed? findings (4)?

Back 28

by cardiac catheterization:

1. Elevation and equalization of the diastolic pressures in each of the cardiac chambers.
2. An early diastolic “dip and plateau” config- uration in the right and left ventricular tracings

3. Prominent Y-descent

4. discordance between RV and LV systolic BP: RV SP rises with inspiration; LV decreases

Front 29

What does this pattern represent?

Back 29

This pattern reflects blood flow into the ventricles at the very onset of diastole, just after the tricuspid and mitral valves open, followed by sudden cessation of filling as further expansion of the ventricles is arrested by the surrounding rigid (constricted) pericardium.

Plateau = square root sign

Front 30

Treatment of constrictive pericarditis

Back 30

1. Treatment of right heart failure:
-diuretics
-salt and water restriction
2. Pericardial stripping