10/2012medslides.com1 Pericardial Disease. 9/98medslides.com2 Pericardial Disease Acute Pericarditis...

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Pericardial Disease


Pericardial Disease

• Acute Pericarditis

• Chronic Relapsing Pericarditis

• Constrictive Pericarditis

• Cardiac Tamponade

• Localized and Low Pressure Tamponade

• Restrictive Cardiomyopathy


Pericardial Anatomy• Two major components– serosa (viceral pericardium)

mesothelial monolayerfacilitate fluid and ion exchange

– fibroa (parietal pericardium)fibrocollagenous tissue

• Pericardial Fluid– 15 - 50 ml of clear plasma ultrafiltrate

• Ligamentous attachments– to the sternum, vertebral column, diaphragm


Pericardial Physiology

• not needed to sustain life

• physiologic functions– limit cardiac dilatation–maintain normal ventricular compliance– reduce friction to cardiac movement – barrier to inflammation– limit cardiac displacement


Pericardial Inflammationpathogenesis

• Contiguous spread– lungs, pleura, mediastinal lymph nodes,

myocardium, aorta, esophagus, liver

• Hematogenous spread– septicemia, toxins, neoplasm, metabolic

• Lymphangetic spread

• Traumatic or irradiation


Pericardial Inflammationpathology

• inflammation provokes a fibrinous exudate with or without serous effusion

• the normal transparent and glistening pericardium is turned into a dull, opaque, and “sandy” sac

• can cause pericardial scarring with adhesions and fibrosis


PERICARDITIS


Acute Pericarditiscommon causes

• Outpatient setting– usually idiopathic– probably due to viral infections– Coxsackie A and B (highly cardiotropic)

are the most common viral cause of pericarditis and myocarditis

– Others viruses: mumps, varicella-zoster, influenza, Epstein-Barr, HIV


Acute Pericarditiscommon causes

• Inpatient settingT = Trauma, TUMORU = UremiaM = Myocardial infarction (acute, post)

Medications (hydralazine, procain)O = Other infections (bacterial, fungal, TB)R = Rheumatoid, autoimmune disorder

Radiation


Acute PericarditisDiagnostic Clues

• Historysudden onset of anterior chest pain that

is pleuritic and substernal

• Physical exampresence of two- or three-component rub

• ECGmost important laboratory clue


Chest Pain Historypericarditis vs infarction

• Common characteristics– retrosternl or precordial with raditaion

to the neck, back, left shoulder or arm

• Special characteristics (pericarditis)–more likely to be sharp and pleuritic with coughing, inspiration, swallowing– worse by lying supine, relieved by

sitting and leaning forward


Heart Murmurs of Pericarditis

• Pericardial friction rub is pathognomic for pericarditis

• scratching or grating sound

• Classically three components:– presystolic rub during atrial filling– ventricular systolic rub (loudest)– ventricular diastolic rub (after A2P2)


Acute PericarditisECG features

• ST-segment elevation– reflecting epicardial inflammation– leads I, II, aVL, and V3-V6– lead aVR usually shows ST depression

• ST concave upward – ST in AMI concave downward like a “dome”

• PR segment depression (early stage)• T-wave inversion– occurs after the ST returns to baseline


Acute PericarditisManagement

• Treat underlying cause

• Analgesic agents– codeine 15-30 mg q 4-6 hr

• Anti-inflmmatory agents– ASA 648 mg q 3-4 hrs– NSAID (indomethacin 25-50 mg qid)– Corticosteroids are symptomatically

effective , but preferably avoided


Chronic Relapsing Pericarditis

• 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


Dressler’s Syndrome• Described by Dressler in 1956

• fever, pericarditis, pleuritis(typically with a low grade fever and a pericardial friction rub)

• occurs in the first few days to several weeks following MI or heart surgery

• incidence of 6-25%

• treat with high-dose aspirin


Acute PericarditisDifferential Diagnosis

• Acute myocardial infarction

• Pulmonary embolism

• Pneumonia

• Aortic dissection


Case Study 1

A 56-year-old man develops recurrent chest discomfort 5 days after an anterior myocardial infarction, which was managed initially with tissue plasminogen activator.

The pain is sharp and positional, radiating toward both clavicles. It is different from the pain associated with his infarction.


Case Study 1

Physical Exam:AfebrileNo pericardial friction rub

ECG: mild PR depression in lead 2no significant change in the evolution pattern of his Q-wave anteroseptal myocardial infarction


Case Study 1

The most appropriate therapy for this patient is:– Salicylates– Indomethacin– Corticosteroids– Colchicine


Case Study 2

A 36-year old woman presents to the ER for the second time in a week with pleuritic chest and left shoulder discomfort and a low-grade fever. She had been in an argument with her boy friend 6 days earlier during which he grabbed her by both shoulders and shook her violently.


Case Study 2

HR 82, BP 94/70.Left iris is green, right is blueShe is slender, has a straight back, long fingers, high-arched palate, and slight pectus excavatum.A pericardial friction rub is present.


Case Study 2

A chest radiograph shows an increased cardiac silhouette and a small left pleural effusion.

ECG shows NSR with diffuse J-point elevation and PR-segment depression in lead 2.


Case Study 2

Which one of the following tests should you order?– An erythrocyte sedimentation rate– A creatine kinase determination– An echocardiogram– An antinuclear antibody– A D-dimer


Constrictive Pericarditis

• rarely develop after an episode of acute idiopathic pericarditis

• more likely to develop after subacute pericarditis with effusion that evolve over several weeks

• more frequent after purulent bacterial or tuberculous pericarditis


Constrictive Pericarditisin the United States

• Idiopathic

• radiotherapy

• cardiac surgery

• connective tissue disorders

• dialysis

• bacterial infection


CONSTRICTIVE PERICARDITIS


Tuberculous Pericarditis

• Incidence of pericarditis in patients with pulmonary TB ranged from 1-8%

• Physical findings: fever, pericardial friction rub, hepatomegaly

• TB skin test usually positive

• Fluid smear for TB often negative

• Pericardial biopsy more definitive


Constrictive Pericarditis Physical Findings

• Jugular veins– prominent X and Y descent with inspiration (Kussmaul’s sign)

• Lungs - possible pleural effusion

• Heart - diastolic pericardial knock

• Abdomen: ascites, pulsatile liver

• Extremities: peripheral edema


Constrictive PericarditisDiagnosis

• often not recognized in its early phases by exam, x-ray, ECG, echo

• tendency to overlook elevated JVP

subacute chronic

diastolic knock + ++

Kussmaul’s + ++

paradoxical pulse ++ ++


Constrictive Pericarditiscatheterization findings

• Right and left heart pressure are measured simultaneously– right and left ventricular diastolic

pressure are elevated and nearly equal; may show classic “square root sign”

– RA pressure has steep X and Y descents and may rise during inspiration (Kussmaul’s sign)


Case Study 3

A 42-year old man presented because of increasing abdominal girth and lower extremity edema. A decade ago he underwent treatment for Hodgkin’s disease that included mantle field radiation therapy and MOPP chemotherapy.


Case Study 3

HR 84, BP 100/70

JVD not observed at 45 degrees

Absent vocal fremitus at right base

Heart sound is distant

An early-mid diastolic sound

3+ pitting edema bilaterally


Case Study 3

What is the most likely diagnosis?– Effusive pericarditis– Occult constrictive pericarditis– Constrictive pericarditis– Idiopathic dilated cardiomyopathy– Restrictive cardiomyopathy


Types of Effusive Fluid

• serous– transudative - heart failure

• suppurative– pyogenic infection with cellular debris and

large number of leukocytes

• hemorrhagic– occurs with any type of pericarditis– especially with infections and malignancies

• serosanguinous


Dignostic Evaluation

• Chest x-ray– usually requires > 200 ml of fluid– cannot distinguish between pericardial

effusion and cardiomegly

• Echocardiography– standard for diagnosing pericardial effusion– convenient, highly reliable, cost effective– false positives (M-mode)- left pleural effusion,

epicardial fat, tumor tissue, pericardial cysts


Noncompressing Effusion

• asymptomatic unless they are large enough to compress adjacent organs– dysphagia– cough– dyspnea– hoarseness– hiccups– abdminal fullness– nausea


ECG in Pericardial Effusion

• Diffuse low voltage– amount of fluid– electrical conductivity of the fluid

• Electrical alternans– alternating amplitude of the QRS– produced by heart swinging motion– also seen in PSVT, HTN, ischemia


Cardiac Tamponade

• Decompensated cardiac compression from increased intracardaic press


Cardiac Tamponade

• Early stage–mild to moderate elevation of central

venous pressure

• Advanced stage intrapericardial pressure

ventricular filling, stroke volume– hypotension – impaired organ perfusion


Beck’s Triad

• Described in 1935 by thoracic surgeon Claude S. Beck

• 3 features of acute tamponade – Decline in systemic arterial pressure– Elevation in systemic venous pressure

(e.g. distended neck vein)– A small, quiet heart


Cardiac TamponadeBedside Diagnosis

• Elevated jugular venous pressure

• Paradoxical pulse


Pulsus Paradoxus

• an exaggerated drop in blood pressure with inspiration (>10mmHg)

• tamponade without pulsus– atrial septal defect– aortic insufficiency– LVH with LVEDP

• pulsus without tamponade– COPD, RV infarct, pulmonary embolism


Echocardiography

• Pericardial effusion– highly reliable

• Cardiac tamponade– RA and RV diastolic collapse– reduced chamber size– distension of the inferior vena cava– exaggerated respiratory variation of the

mitral and tricuspid valve flow velocities


Pericardiocentesis

• 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


Pericardial Window

• Balloon dilatation of a needle pericardiostomy

• subxyphoid surgical pericardiostomy

• video-assisted thoracoscopy with localized pericardial resection

• anterolateral thoracotomy with parietal pericardial resection


Localized and Low PressureCardiac Tamponade

• Localized tamponadedue to loculated pericardial effusion

• Low pressure tamponadedue to relative intravascular volume depletion


Restrictive Cardiomyopathy

• Differentiation from constrictive pericarditis may be difficult from intracardiac pressure tracings

• clues from history, physical exam, ECG, echo, CT and MR scan

• amyloidosis is most likely to simulate constrictive pericarditis

10/2012medslides.com1 Pericardial Disease. 9/98medslides.com2 Pericardial Disease Acute Pericarditis...

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