ICMII Cardiology Lecture 7 – Pericardial Diseases

2 layers of pericardium
Parietal = fibrous external
Visceral = adjacent to epicardium

Normal fluid level of serous fluid at pericardium?
15 cc

Acute Pericarditis: causes
70% idiopathic (assumed viral)
Coxsackie, echovirus, adenovirus, influenza, HIV
TB, histoplasmosis
Prululent = bacterial
Neoplastic
Radiation
Connective tissue disease
Post MI = Dresslers
Uremia

Presenting symptoms of Acute pericarditis?
Pleuritic chest pain = sharp, stabbing, *worse on inspiration*, worse with *laying flat*. Improves with leaning forward, *Radiates to Left Trapezius Ridge*
Fever, malaise, dyspnea, URI
Sinus Tachycardia
Fever
Pericardial Friction rub
*Diffuse convcave ST elevations*
*PR depression*

Differential diagnosis for acute pericarditis?
Acute coronary syndrome
Pulmonary embolism
Pneumothorax
Pneumonia
Pleurisy
Musculoskeletal
Myocarditis
Esophageal

What is a pericardial rub?
Scratchy, lether, higher pitch than diastolic filling
Triphasic 50%, biphasic 33%
Hear better if pt leaning forward
Comes and goes, varies intensity
It is the Visceral and parietal pericardium rubbing together

Diffuse concave ST elevations and PR segment depression (PR elevation in aVR)
Acute Pericarditis

CXR for acute pericarditis?
normal

When do you do pericardiocentesis?
With purulent pericarditis, malignancy or large effusion, tamponade

Tx of Acute pericarditis?
High dose aspirin (2-6g/day)
NSAIDS
Colchicine
Corticosteroids
Pericardiocentesis for tamponade or purulent pericarditis
Hemodyalisis for uremic pericarditis

Complications of acute pericarditis?
Effusion and tamponade
Constrictive pericarditis later
Relapse

Causes of Pericardial effusion?
*Acute pericarditis
Radiation
Malignancy*
Cardiac perforation
Hypothyroidism
conn tissue disease
Post MI
Chronic renal failure
aortic dissection

How does Pericardial tamponade affect pressures and filling?
Increased intrapericardial pressure impedes diastolic filling of *LV and RV*
Stroke volume and CO and Mean arterial pressure decrease
Systemic BP drop = hypotension
Pulse pressure *narrows*
*HR increases*

How does pericardial tamponade present physically and on imaging?
CHF symptoms but clear lungs
Edema, increased JVP
Cardoimegaly on CXR
Sinus tachycardia, low voltage, *electrical alternans*
Pulsus paradoxus

Sinus tachycardia
Tachypnea
Hypotension
Narrow pulse pressure
Elevated JVP, *loss of Y descent*
Edema
*Pulsus Paradoxus*
Pericardial tamponade

Why does pericardial tamponade cause pulsus paradoxus?
Fluid compresses septum to shift towards LV, impinging LV volume. Inspiration increases venous return,RV free wall can’t expand, causing septal shift that impinges on LV volume. This causes *diminished stroke volume* and less pulse on inspiration

Loss of y descent on JVP?
Loss of y descent on JVP?
Tamponade. So after A wave, X trough, your V wave continues to go up (skips Y wave) to A wave. Looks like right image, but slow ascent not flatline at end

Elevated JVP with prominent X and Y descents
Constrictive pericarditis

What tools do you use to diagnose pericardial tamponade?
History, physical, ECG, CXR, echo with doppler, and *Right heart catherterization* to see *equalization of pressures*

What do hemodynamics look like on *Constrictive pericarditis*?
Eqaualization of LV and RV diastolic pressures

Tx of pericardial tamponade
Medical emergency
IV fluids (temporizing)
*DO NOT USE Diuretics or Vasodilators*
Vasopressors as needed
Quick Pericardiocentesis
Pericardial window

Define Constrictive pericarditis
Chronic thickening/scarring of pericardium causes encasement of heart = *impaired diastolic filling of LV and RV*
But *Early diastolic filling is unimpaired*
Its just the later that is impaired
Dip and plateu or square root sign on pressure graph

square root sign pericarditis
square root sign pericarditis
Dip followed by plateau = constrictive pericarditis

Causes of constrictive pericarditis?
Idiopathic/viral = 50%
Post cardiac surgery = 20%
Radiation = 20%
Conn tissue = 5%
Post TB = 5%

How does constrictive pericarditis present?
Slow, indolent process
*unexplained Right heart failure* with Edema, ascites, hepatomegaly, fatigue, dyspnea
Often is confused with cirrhosis

Physical exam findings of *constrictive* pericarditis
Elevated JVP with prominent X and Y
Kussmauls sign
Pericardial knock
Systemic congestion (hepatomegaly, ascites, edema)

Tamponade vs constriction JVP traces
Tamponade vs constriction JVP traces
Tamponade = no Y descent
Constrictive = Prominent X and Y descents

When does pericardial knock happen?
Constrictive pericarditis, after S2

Calcification on CXR
Pericardial thickening on CT
Constrictive pericarditis

How do you treat Constrictive pericarditis?
Diuretics (unlike tamponade)
Pericardial stripping – difficult procedure

Radial pulse obliterates on inspiration
pulsus paradoxus

ECG shows tachycardia, low voltage, electrical alternans
Tamponade

What is kussmaul sign?
Paradoxal rise in JVP on inspiration (seen in constritctive pericarditis or Right heart failure)

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What are the 3 functions of the pericardium? fixes heart in mediastinum (limits motion), prevents extreme dilation of heart during sudden rises of intracardiac volume, and barrier to limit spread of infection What are the 3 causes of pericarditis? infectious …

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Which heart sound could sound like “Ten-nes-see” and is also known as the atrial gallop? 4th Heart Sound or S4 Which heart sound could sound like “Ken-tuc-ky” and is also known as the ventricular gallop? 3rd Heart Sound or S3 …

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