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Pericardial Disease 10/2012 medslides.com
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Pericardial Disease Acute Pericarditis Chronic Relapsing Pericarditis
Constrictive Pericarditis Cardiac Tamponade Localized and Low Pressure Tamponade Restrictive Cardiomyopathy 9/98 medslides.com
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Pericardial Anatomy Two major components
serosa (viceral pericardium) mesothelial monolayer facilitate fluid and ion exchange fibroa (parietal pericardium) fibrocollagenous tissue Pericardial Fluid ml of clear plasma ultrafiltrate Ligamentous attachments to the sternum, vertebral column, diaphragm 9/98 medslides.com
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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 9/98 medslides.com
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Pericardial Inflammation pathogenesis
Contiguous spread lungs, pleura, mediastinal lymph nodes, myocardium, aorta, esophagus, liver Hematogenous spread septicemia, toxins, neoplasm, metabolic Lymphangetic spread Traumatic or irradiation 9/98 medslides.com
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Pericardial Inflammation pathology
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 9/98 medslides.com
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PERICARDITIS 9/98 medslides.com
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Acute Pericarditis common 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 9/98 medslides.com
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Acute Pericarditis common causes
Inpatient setting T = Trauma, TUMOR U = Uremia M = Myocardial infarction (acute, post) Medications (hydralazine, procain) O = Other infections (bacterial, fungal, TB) R = Rheumatoid, autoimmune disorder Radiation 9/98 medslides.com
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Acute Pericarditis Diagnostic Clues
History sudden onset of anterior chest pain that is pleuritic and substernal Physical exam presence of two- or three-component rub ECG most important laboratory clue 9/98 medslides.com
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Chest Pain History pericarditis 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 9/98 medslides.com
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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) 9/98 medslides.com
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Acute Pericarditis ECG 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 9/98 medslides.com
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Acute Pericarditis Management
Treat underlying cause Analgesic agents codeine mg q 4-6 hr Anti-inflmmatory agents ASA 648 mg q 3-4 hrs NSAID (indomethacin mg qid) Corticosteroids are symptomatically effective , but preferably avoided 9/98 medslides.com
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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 9/98 medslides.com
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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 9/98 medslides.com
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Acute Pericarditis Differential Diagnosis
Acute myocardial infarction Pulmonary embolism Pneumonia Aortic dissection 9/98 medslides.com
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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. 9/98 medslides.com
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Case Study 1 Physical Exam: Afebrile No pericardial friction rub ECG: mild PR depression in lead 2 no significant change in the evolution pattern of his Q-wave anteroseptal myocardial infarction 9/98 medslides.com
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Case Study 1 The most appropriate therapy for this patient is:
Salicylates Indomethacin Corticosteroids Colchicine 9/98 medslides.com
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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. 9/98 medslides.com
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Case Study 2 HR 82, BP 94/70. Left iris is green, right is blue She is slender, has a straight back, long fingers, high-arched palate, and slight pectus excavatum. A pericardial friction rub is present. 9/98 medslides.com
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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. 9/98 medslides.com
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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 9/98 medslides.com
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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 9/98 medslides.com
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Constrictive Pericarditis in the United States
Idiopathic radiotherapy cardiac surgery connective tissue disorders dialysis bacterial infection 9/98 medslides.com
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CONSTRICTIVE PERICARDITIS
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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 9/98 medslides.com
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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 9/98 medslides.com
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Constrictive Pericarditis Diagnosis
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 9/98 medslides.com
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Constrictive Pericarditis catheterization 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) 9/98 medslides.com
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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. 9/98 medslides.com
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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 9/98 medslides.com
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Case Study 3 What is the most likely diagnosis? Effusive pericarditis
Occult constrictive pericarditis Constrictive pericarditis Idiopathic dilated cardiomyopathy Restrictive cardiomyopathy 9/98 medslides.com
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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 9/98 medslides.com
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Dignostic Evaluation Chest x-ray Echocardiography
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 9/98 medslides.com
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Noncompressing Effusion
asymptomatic unless they are large enough to compress adjacent organs dysphagia cough dyspnea hoarseness hiccups abdminal fullness nausea 9/98 medslides.com
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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 9/98 medslides.com
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Cardiac Tamponade Decompensated cardiac compression from increased intracardaic press 9/98 medslides.com
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Cardiac Tamponade Early stage Advanced stage
mild to moderate elevation of central venous pressure Advanced stage intrapericardial pressure ventricular filling, stroke volume hypotension impaired organ perfusion 9/98 medslides.com
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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 9/98 medslides.com
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Cardiac Tamponade Bedside Diagnosis
Elevated jugular venous pressure Paradoxical pulse 9/98 medslides.com
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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 9/98 medslides.com
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Echocardiography Pericardial effusion Cardiac tamponade
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 9/98 medslides.com
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Pericardiocentesis Diagnostic tap Therapeutic drainage
usually not indicated rarely have positive cytology or infection that can be diagnosed Therapeutic drainage indicated for significant elevation of the central venous pressure 9/98 medslides.com
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Pericardial Window Balloon dilatation of a needle pericardiostomy
subxyphoid surgical pericardiostomy video-assisted thoracoscopy with localized pericardial resection anterolateral thoracotomy with parietal pericardial resection 9/98 medslides.com
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Localized and Low Pressure Cardiac Tamponade
Localized tamponade due to loculated pericardial effusion Low pressure tamponade due to relative intravascular volume depletion 9/98 medslides.com
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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 9/98 medslides.com
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