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IM - PERICARDIAL DISEASES

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tonystep1's version from 2017-08-27 09:09

PERICARDIAL DISEASES CLINICAL FEATURES

Question Answer
Acute Pericarditis1.Chest pain (not always present)
a. Often severe and pleuritic (can differentiate from pain of MI because of association
with breathing)
b. Often localized to the retrosternal and left precordial regions and radiates to the
trapezius ridge and neck
c. Pain is positional: It is aggravated by lying supine, coughing, swallowing, and
deep inspiration. Pain is relieved by sitting up and leaning forward.
d. Pain is not always present, depending on the cause (e.g. , usually absent in
rheumatoid pericarditis)
2. Fever and a nonproductive cough may be present.
3. Pericardia! friction rub - Scratching, high-pitched sound with three components
Constrictive Pericarditisl . Patients appear very ill.
2. Initial manifestations are secondary to systemic venous pressure elevation: edema,
ascites, hepatic congestion.
Later manifestations are due to elevation of left-sided intracardiac pressures:
pulmonary congestion-cough, exertional dyspnea, and orthopnea.
Jugular venous distention (JVD)-
Kussmauls sign-JVD (venous pressure) fails to decrease during inspiration
Pericardia! knock-corresponding to the abrupt cessation of ventricular
filling
Pericardial Effusionl. Muffled heart sounds
2. Soft PMI
3. Dullness at left lung base (because it may be compressed by pericardia! fluid)
4. Pericardia! friction rub may or may not be present.
Cardiac Tamponade1.Elevated jugular venous pressure is the most common finding (distended
neck veins).
2.Narrowed pulse pressure (due to decreased stroke volume)
3. Pulsus paradoxus
a. Exaggerated decrease in arterial pressure during inspiration (> 10 mm Hg drop)
4. Distant (muffled) heart sounds
5. Tachypnea, tachycardia, and hypotension with onset of cardiogenic shock
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PERICARDIAL DISEASES DIAGNOSIS

Question Answer
Acute Pericarditisa. Diffuse S-T elevation and PR depression
b. S-T segment returns to normal
c. T wave inverts
d. T wave returns to normal
Constrictive Pericarditisl. ECG
a. Low QRS voltages, generalized T wave flattening or inversion, left atrial abnormalities
2. Echocardiogram shows a thickened pericardium but cannot definitively exclude
the diagnosis.
3. CT scan and MRI also show pericardia! thickening, but are more accurate than
echocardiogram.
4. Cardiac catheterization
a. Elevated and equal diastolic pressures in all chambers
b. Ventricular pressure tracing shows a rapid y descent, which has been described
as a dip and plateau or a "square root sign."
Pericardial Effusionl. Echocardiogram
a. Imaging procedure of choice: Confirms the presence or absence of a significant
effusion
b. Most sensitive and specific method of determining whether pericardia! fluid is
present; can show as little as 20 mL of fluid
2. CXR
a. CXR shows enlargement of cardiac silhouette when > 250 mL of fluid has
accumulated.
b. Cardiac silhouette may have prototypical "water bottle" appearance.
c. An enlarged heart without pulmonary vascular congestion suggests pericardia!
effusion.
Cardiac Tamponadel. Echocardiogram
a. Must be performed if suspicion of tamponade exists based on history/
examination
b. Usually diagnostic; the most sensitive and specific noninvasive test
2. CXR
a. Enlargement of cardiac silhouette when > 250 mL has accumulated
b. Clear lung fields
3. ECG
a. Electrical alternans (alternate beat variation in the direction of the ECG waveforms)-
due to pendular swinging of the heart within the pericardia! space,
causing a motion artifact
b. Findings are neither 100% sensitive nor specific. ECG should not be used to
diagnose tamponade.
4. Cardiac catheterization
a. Shows equalization of pressures in all chambers of the heart
b. Shows elevated right atrial pressure with loss of the y descent
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PERICARDIAL DISEASE TREATMENT AND MANAGEMENT

Question Answer
Acute Pericarditisl. Most cases are self-limited and resolve in 2 to 6 weeks.
2. Treat the underlying cause if known.
3. NSAIDs are the mainstay of therapy (for pain and other systemic symptoms).
4. Glucocorticoids may be tried if pain does not respond to NSAIDs, but should be
avoided if at all possible.
Constrictive PericarditisSurgical: Complete resection of the pericardium is definitive therapy and is indicated
in many patients. It has a significant mortality rate, however.
Pericardial Effusionl. Depends on patient's hemodynamic stability
2. Pericardiocentesis is not indicated unless there is evidence of cardiac tamponade.
Analysis of pericardia! fluid can be useful if the cause of the effusion is
unknown.
3. If the effusion is small and clinically insignificant, a repeat echocardiogram in
l to 2 weeks is appropriate.
Cardiac Tamponade Nonhemorrhagica. If patient is hemodynamically stable
• Monitor closely with echocardiogram, CXR, ECG
• If patient has known renal failure, dialysis is more helpful than pericardiocentesis.
b. If patient is not hemodynamically stable
• Pericardiocentesis is indicated.
• If no improvement is noted, fluid challenge may improve symptoms
Cardiac Tamponade hemorrhagic2. Hemorrhagic tamponade secondary to trauma
a. Emergent surgery is indicated to repair the injury.
b. Pericardiocentesis is only a temporizing measure and is not definitive treatment.
Surgery should not be delayed to perform pericardiocentesis.
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