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Medicine Phase 2a CVS > Pericarditis > Flashcards

Pericarditis Flashcards

1
Q

Describe the pericardium

A

Acts as a protective covering for the heart

Consists of an outer fibrous pericardial sac and inner serous pericardium.

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2
Q

What layers make up the inner serous pericardium

A

Inner visceral epicardium
50 ml Serous fluid
Outer parietal pericardium

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3
Q

Describe the inner visceral epicardium

A

Single cell layer adherent to myocytes of the epicardium, that lines the heart and great vessels

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4
Q

What is purpose of the serous fluid of inner serous pericardium?

A

Acts as a lubricant to allow two surfaces to move over each other easily

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5
Q

What makes up the outer parietal pericardium

A

mainly collagen and elastin fibres (with no cells)

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6
Q

Pros of pericardium

A

It promotes cardiac efficiency by limiting dilation, maintaining ventricular compliance and distributing hydrostatic forces

Aids atrial filling by creating a closed chamber, reduces external friction and acts as a barrier against infection and extension of malignancy

Anatomically fixes the heart to the sternum, diaphragm and costal cartilages

Initially stretchy but becomes stiff at higher tension

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7
Q

If the proximal segment (ascending) of the aorta is ruptured, where will it bleed into?

A

The pericardial space

Result in a cardiac tamponade if even a small volume of fluid is added to this space.

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8
Q

Which heart chamber mainly lies outside the pericardium

A

Left atrium

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9
Q

Define acute pericarditis

A

Acute inflammation of the pericardium, with or without effusion

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10
Q

Acute pericarditis epidemiology

A

Majority are idiopathic and most commonly seen in the young, previously healthy patient
Occurs in men more than women
Occurs in adults more than children

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11
Q

Acute pericarditis aetiology - infectious causes

A

Viral (common) - Enteroviruses (e.g. coxsackieviruses & echoviruses) or Adenoviruses

Bacterial - Mycobacterium tuberculosis

Fungal (rare) - Histoplasma spp. (generally in immuno-compromised patient)

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12
Q

Acute pericarditis aetiology - non-infectious causes

A

Autoimmune (common):
• Sjorgrens syndrome
• Rheumatoid arthritis
• SLE

Neoplastic; secondary metastatic tumours (generally lung or breast cancer)

Dressler’s syndrome - post cardiac injury syndromes

Traumatic and iatrogenic

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13
Q

Acute pericarditis aetiology - non-infectious causes - examples of early onset traumatic causes

A

Direct injury - penetrating thoracic injury or oesophageal perforation
Indirect injury - non-penetrating thoracic injury or radiation

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14
Q

Acute pericarditis aetiology - non-infectious causes - examples of delayed onset traumatic causes (common)

A

Pericardial injury syndromes (common)

Iatrogenic trauma e.g. coronary percutaneous intervention or pacemaker lead insertion

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15
Q

Acute pericarditis pathophysiology

A

Pericardium becomes acutely inflamed, with pericardial vascularisation and
infiltration with polymorphonuclear leukocytes

A fibrinous reaction frequently results in exudate and adhesions within the
pericardial sac, and a serous or haemorrhagic effusion may develop

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16
Q

Clinical presentation of Acute pericarditis

A

Chest pain
Dyspnoea
Cough
Hiccups (due to phrenic involvement)
Pericardial friction rub present on auscultation
Fever and lymphocytosis (increase in lymphocytes) if due to virus or bacteria
Tachycardia

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17
Q

Describe chest pain from acute pericarditis

A
  • Severe
  • Sharp & pleuritic (without constricting crushing character of ischaemic pain)
  • Rapid onset
  • Worse on inspiration or lying flat - relieved by sitting forward
  • Left anterior chest or epigastrium
  • Radiates to arm, more specifically the trapezius ridge (has co- innervation with the phrenic nerve) - whereas a STEMI would be arms, jaw & teeth
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18
Q

Differential diagnosis of acute pericarditis

A
  • Angina
  • MI (most important to rule out)
  • Pleuritic pain
  • Pulmonary infarction
  • Pneumonia, GI reflux, peritonitis & aortic dissection
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19
Q

Diagnosis of acute pericarditis: Describe ECG

A
  • Is diagnostic
  • Widespread concave-upwards - SADDLE SHAPED ST ELEVATION (arrowed)
  • Diffuse ST segment elevation - present in all leads (must exclude STEMI which would have ST segment elevation but will be limited to the infarcted area e.g. anterior or inferior)
  • PR depression
20
Q

Diagnosis of acute pericarditis: Describe Chest X-ray

A
  • May demonstrate cardiomegaly in cases of effusion - if found then confirm with echocardiography
  • Often normal in idiopathic
  • Pneumonia is common with bacterial pericarditis
21
Q

Diagnosis of acute pericarditis: Describe Full Blood Count

A
  • Slight increase in white cell count
  • Anti Neutrophil Antibody in young females - SLE
  • Troponin - elevated suggests myopericarditis
22
Q

Diagnosis of acute pericarditis: DescribeESR/CRP

A

• High ESR is indicative of autoimmune

23
Q

Treatment of acute pericarditis

A
  • Restrict physical activity until resolution of symptoms and see improvement in ECG and CRP
  • NSAID e.g Ibuprofen for two weeks or Aspirin for two weeks
  • Colchicine for 3 weeks however is limited by nausea and diarrhoea but does reduce recurrence
24
Q

What % of acute pericarditis cases go onto develop idiopathic relapsing pericarditis?

A

20%

25
Q

Treatment of recurrent/relapsing pericarditis

A
  • The first line treatment is oral NSAIDs e.g. Ibuprofen
  • Colchicine has been proven to be more effective than Aspirin alone
  • In resistant cases, oral corticosteroids e.g. Prednisolone may be effective, and in some patients, pericardiectomy (removal of part/most of the pericardium) may be appropriate
26
Q

Define pericardial effusion

A

A collection of fluid within the potential space of the serous pericardial sac
(commonly accompanies episode of acute pericarditis)

27
Q

What is a cardiac tamponade

A 
Pericardial effusion (large volume of fluid collecting) in potential space of serous pericardial sac. 
Causes compromise of ventricular filling and decreased circulation
28
Q

Clinical presentation of peripheral effusion

A

Symptoms of a pericardial effusion commonly reflect the underlying pericarditis
Soft & distant heart sounds Apex beat obscured
Raised jugular venous pressure
Dysponea

29
Q

Clinical presentation of cardiac tamponade

A
  • High pulse but low blood pressure
  • High jugular venous pressure
  • Muffled 1st & 2nd heart sounds
  • Kussmaul’s sign
  • Pulsus paradoxus
  • Reduced cardiac output
30
Q

What is Kussmaul’s sign

A

rise in jugular venous pressure and increased neck vein distension during inspiration

31
Q

What is Pulsus paradoxus

A

an exaggeration in the normal variation in pulse pressure seen with inspiration, such that there is a drop in systolic blood pressure

32
Q

Diagnosis of pleural effusion

A 
CXR:
• Large globular heart
ECG:
• Low-voltage QRS complexes 
• Sinus tachycardia
Echocardiogram:
• Most useful for demonstrating effusion 
• Echo-free zone surrounding heart
33
Q

Diagnosis of cardiac tamponade

A

CXR: Big globular heart

Beck’s triad

ECG: Low voltage QRS

Echocardiogram: (DIAGNOSTIC)
• Echo-free zone around heart
• Late diastolic collapse of RIGHT ATRIUM (remember most of L atrium is
outside pericardium)
• Early diastolic collapse of right ventricle

34
Q

What is Beck’s triad (diagnosis of cardiac tamponade)

A
  • Falling blood pressure
  • Rising jugular venous pressure
  • Muffled heart sounds
35
Q

Treatment of pleural effusion

A

Underlying cause should be sought and treated if possible
Most pericardial effusions resolve spontaneously
Pericardial Fenestration in some cases

36
Q

What is most common cause of a pericardial effusion re-accumulating

A

Malignancy

37
Q

What is meant by Pericardial Fenestration and when would it be used?

A

A window in the pericardium is created to allow the slow release of fluid into the surrounding tissues.
Treat re-accumulating peripheral effusions due to malignancy

38
Q

Treatment of cardiac tamponade

A

See expert help!

Require URGENT DRAINAGE via a PERICARDIOCENTESIS which will drain the fluid to relieve the pressure on the heart

Send fluid for culture, Ziehl-Nielsen stain and for cytology

39
Q

Aetiology of constrictive pericarditis

A

Cause is often unknown and can occur after any pericarditis
Certain causes of pericarditis such as tuberculosis, bacterial infection and rheumatic heart disease result in the pericardium becoming thick, fibrous and calcified

40
Q

Pathophysiology of constrictive pericarditis

A

In many cases, pericardial changes do not cause symptoms, however if the pericardium becomes so inelastic as to interfere with the diastolic filling of the heart, you develop constrictive pericarditis.
Changes are chronic allowing body time to compensate (UNLIKE Cardiac Tamponade)

41
Q

Why is it important to distinguish Constrictive pericarditis from Restrictive endocarditis?

A

Constrictive pericarditis is treatable

42
Q

Describe later stage pathophysiology of constrictive pericarditis

A

sub-endocardial layers of myocardium may undergo fibrosis, atrophy and calcification

43
Q

Clinical presentation of constrictive pericarditis

A 
Kussmaul's sign
Pulsus paradoxus
Diffuse heart sounds
Ascites
Oedema
Right HF signs
Atrial dilation
44
Q

Diagnosis of constrictive pericarditis

A

CXR: Small heart with/without pericardial calcification

ECG: Low-voltage QRS

Echocardiography:
• Thickened, calcified pericardium
• Small ventricular cavities with normal wall thickness

45
Q

Treatment of constrictive pericarditis

A

Complete resection of the pericardium

risky/high complication rate

Medicine Phase 2a CVS (17 decks)

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