Pericardial and Myocardial Cases-Henkin

Question 1

Classification or Pericardial diseases

Answer 1

Pericarditis (Acute/recurrent/chronic), pericardial effusions, (without inflammation from other causes-traumatic, infiltrated) Pericardial compressive syndromes (cardiac tamponade, constrictive pericarditis), Other rare diseases (congenital absence, cysts, primary tumors-metastasis more common)

Question 2

What determines whether or not fluid causes tamponade (contraction impedance)?

Answer 2

1. Amount of fluid, 2. Rate of fluid production (gradual)

Question 3

Most common causes of pericardial effusion/inflammation

Answer 3

Viral (assume unless proven otherwise) and idiopathic

Question 4

Other causes of pericardial effusion/inflammation

Answer 4

Bacterial/fungal, Traumatic, mechanical after surgery (damage causing autoimmune reaction to pericardium), Kidney disease, dialysis patients will have fluid, Hypothyroidism, HIV more common, Metastasis, Pregnancy by itself (our patient!) can cause a small amount of PE dt fluid overload like peripheral edema (not autoimmune), Radiation therapy , Chemotherapy-some, Some medications that cause autoimmune reactions..

Question 5

What are the physical exam signs of pericarditis?

Answer 5

Normal BP, clear lungs, normal heart sounds, scratchy sound over precordium-pericardial frictino rub (like scratchy paper, louder when leans forward and heart is against chest wall. 3 components: diastole, presystole/atrial systole and systole), biphasic or monophasic systolic murmur.

Question 6

What does the EKG show in pericarditis?

Answer 6

ST elevation in almost all leads. PR depression. T wave doesn’t become inverted when ST still elevated. Can also be lower QRSs, some Pulsus alternans.

Question 7

Lab tests in pericarditis

Answer 7

Inflammation, increased sedimentation rate (ESR), leukocytosis, increase in myocardial enzymes if myocarditis but often normal.

Question 8

What is the primary treatment for pericarditis?

Answer 8

Antiinflammatories

Question 9

What are the symptoms of pericarditis

Answer 9

Muscle and chest pain, fever. Retrosternal or epigastric can radiate to neck or trapezius area aggravated by cough and deep breath, recumbancy, eased by leaning forward.

Question 10

Differential diagnoses with acute pericarditis

Answer 10

If not typical check enzymes for MI just in case. Pneumonia (fever and chest pain), dissecting aortic aneurysm.

Question 11

What is the CXR like in constrictive pericarditis?

Answer 11

Large, waterbottle shape, equally large L and R sides.

Question 12

How to measure pulsus paradoxis

Answer 12

inflate the BP sleeve to above systolic BP and slowly decrease pressure until start hearing a sound (systolic BP). At first will only hear it during expiry not inspiry. Only when decrease more will hear inspirum. Because during inspirum increases venous return. Sign of tamponade.

Question 13

What are the 2 pericardial constrictive syndromes?

Answer 13

Cardiac tamponade (from fluid, acute), Constrictive pericarditis (chronic inflammation). Can also be in between.

Question 14

What happens with increased diastolic pressure in one chamber?

Answer 14

Equilization across all 4 chambers.

Question 15

What is the effect of increased right sided pressure?

Answer 15

Impeded venous return: increased jugular venous pressure, increased CVP, hepatomegaly, edema, asciites.

Question 16

What is the effect of increased left sided pressure:?

Answer 16

Decreased cardiac output, compensatory tachycardia.

Question 17

Pathophysiology in chambers of impared diastolic filling

Answer 17

Decreased ventricular volume, increased diastolic pressures, decreased diastolic compliance, preserved systolic function, ventricular coupling

Question 18

Mechanism of pulsus paradoxus

Answer 18

Usually during inspirum, get increase in venous return, with septum tending to bulge into LV because more blood in R side pushes septum towards left side but if pericardium is elastic, L side can also expand and doesn’t effect volume or pressure much. If fixed and doesn’t allow expansion, bulging of septum will reduce CO and reduce blood pressure.

Question 19

How are the signs of tamponade similar and different from pulmonary edema?

Answer 19

Both have low BP, extended JV, pulsus paradoxus. Clear lungs.

Question 20

What is the physical exam presentation in cardiomyopathy?:

Answer 20

Tachypnea, tachycardia, normal BP, extended jugular veins, mild rales, soft heart sounds, gallop rhythm with S4, enlarged liver, pitting edema in legs.

Question 21

What is the appearance of the CXR in cardiomyopathy?

Answer 21

Enlarged left heart.

Question 22

Definition of cardiomyopathy

Answer 22

A disease involving the heart muscle of unknown etiology. Primary so must exclude: MI, HTN, congenital HF, valvular, pericardial.

Question 23

Primary classification of cardiomyopathies

Answer 23

Dilated (DCM), hypertrophic (HCM), Restrictive.

Question 24

Secondary classification of CMP

Answer 24

Infective (usually viral), Familial storage diseases (accumulation of glycogen or polysaccharides in myocardium), electrolyte/vimatim deficiencies, infiltrations of other cells or substances (hemochromatosis/iron accumulation), Toxic causes, Peripartum (two months before or after birth), drugs

Question 25

Drugs causing CMP

Answer 25

Chemo (Doxorubicin, cyclophsphamide, 5FU, herceptin), cocaine (blood vessels, small MIs)

Question 26

Exclusionary differential diagnoses with secondary CMP:

Answer 26

Alcohol (abstinence), hypo and hyperthyroid, hemochromatosis (can remove iron), hypocalcemia/phosphatemia, HIV, chronic tachycardia (from arrhythmias like afib that can weaken the heart over time, treatment restores contraction to normal), Tako-Tsubo, peripartum (last few weeks of pregnancy, can be reversible but can’t get pregnant again), noncompaction (embryogenesis)

Question 27

What is Tako Tsubo

Answer 27

Stress cardiomyopathy more common in women often, can see ST elevation like an MI, base of ventricle looks normal then see ballooning. Catheterize and all vessels are open with no obstruction. Not a true MI because after a few days disappears, outsurge of catecholamines, after a few days pt rests and goes away.

Question 28

Treatment of CMP

Answer 28

Like any other heart failure (beta blockers, etc)

Question 29

Physical exam in Hypertrophic cardiomyopathy

Answer 29

Brisk pulse, jugular veins not extended, clear lungs, S4 heart sound, mid/late systolic murmur (at left sternal border/apex).

Question 30

How is the EKG in hypertrophic cardiomyopathy?

Answer 30

LV hypertrophy, sinus rhythm, ST depression and T inversion .

Question 31

What appears in the echo of hypertrophic cardiomyopathy:?

Answer 31

Bulging of septum, mitral valve blocks aortic outflow, systolic anterior motion (SAM) of mitral valve.

Question 32

What needs to be excluded to diagnose cardiac myopathy?

Answer 32

HTN, aortic stenosis, LV dilation.

Question 33

Hypertrophic cardiomyopathy classification

Answer 33

Non-obstructive and obstructive, Assymetric (more in obstructive) and Symmetric.

Question 34

What causes diastolic dysfunction in Hypertrophic CMP?

Answer 34

Thick myocardium that can’t contract properly. Stiff and impedence to filling, high resistance/LVEDP.

Question 35

Mechanical difference between aortic stenosis and hypertrophic CMP?

Answer 35

Aorta is constantly constricted in aortic stenosis whereas starts normal in HC and pressure drops and valve flops in the way.

Question 36

Factors that increase and lengthen murmur or make it stronger in hypertrophic cardiomyopathy

Answer 36

Hypertrophy increases by decreasing afterload (LV size decreases and obstruction increases), increased contractility (LV contracts). Ex: Valsalva (increases venous return), standing up, exercise (increases contractility), hypovolemia, tachycardia and medications.

Question 37

Factors that decrease obstruction in hypertrophic cardiomyopathy

Answer 37

Increase venous return with increased afterload.

Question 38

Complications of hypertrophic CMP

Answer 38

AFib, dilated CMP, ischemia (thick with no new vessels, high pressure), arrhythmias and sudden cardiac death, dilated cardiomyopathy with systolic dysfunction.

Question 39

What treatment should be avoided in HCMP?

Answer 39

Digitalis or anything that increases contractility or decreases volume of the ventricle.

Question 40

Treatment for hypertrophic CMP

Answer 40

Beta blockers and calcium channel blockers to reduce contractility. A pacemaker will decrease contractility-dyssynchrony of contraction. ICD to prevent arrhythmia and sudden death. Surgery: septal myectomy to decrease symptoms if no other treatment worked.