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C46 Cardiology and Cardiac Surgery
Pericardial Disease
Toronto Notes 2019
Acute Pericarditis Triad
• Chest pain
• Friction rub • ECG changes
Pericardial Disease
Acute Pericarditis
Etiology of Pericarditis/Pericardial Effusion
• idiopathicismostcommon:presumedtobeviral
• infectious
■ viral: Coxsackie virus A, B (most common), echovirus ■ bacterial: S. pneumoniae, S. aureus
■ TB
• fungal: histoplasmosis, blastomycosis
• post-MI:acute(directextensionofmyocardialinflammation,1-7dpost-MI),Dressler’ssyndrome
(autoimmune reaction, 2-8 wk post-MI)
• post-cardiacsurgery(e.g.CABG),othertrauma
• metabolic:uremia(common),hypothyroidism
• neoplasm: Hodgkin’s, breast, lung, renal cell carcinoma, melanoma
• collagenvasculardisease:SLE,polyarteritis,rheumatoidarthritis,scleroderma
• vascular:dissectinganeurysm
• other:drugs(e.g.hydralazine),radiation,infiltrativedisease(sarcoid)
Signs and Symptoms
• diagnostictriad:chestpain,frictionrub,andECGchanges(diffuseSTelevationandPRdepressionwith reciprocal changes in aVR)
• pleuriticchestpain:alleviatedbysittingupandleaningforward
• pericardialfrictionrub:maybeuni-,bi-,ortriphasic;evanescentandrare
• ±fever,malaise
Investigations
• ECG:initiallydiffuseelevatedSTsegments±depressedPRsegment,theelevationintheSTsegmentis concave upwards → 2-5 d later ST isoelectric with T wave flattening and inversion
• CXR:normalheartsize,pulmonaryinfiltrates
• Echo:performedtoassessforpericardialeffusion
Treatment
• treattheunderlyingdisease
• anti-inflammatoryagents(highdoseNSAIDs/ASA,steroidsusecontroversial),analgesics
• colchicinereducestherateofincessant/recurrentpericarditis(ICAPNEnglJMed2013;369:1522-1528)
Complications
• recurrentepisodesofpericarditis,atrialarrhythmia,pericardialeffusion,tamponade,constrictivepericarditis
Pericardial Effusion
Etiology
• transudative(serous)
• CHF, hypoalbuminemia/hypoproteinemia, hypothyroidism • exudative(serosanguinousorbloody)
■ causes similar to the causes of acute pericarditis
■ may develop acute effusion secondary to hemopericardium (trauma, post-MI myocardial rupture,
aortic dissection)
• physiologicconsequencesdependontypeandvolumeofeffusion,rateofeffusiondevelopment,and
underlying cardiac disease
Signs and Symptoms
• maybeasymptomaticorsimilartoacutepericarditis
• dyspnea, cough
• extra-cardiac(esophageal/recurrentlaryngealnerve/tracheo-bronchial/phrenicnerveirritation) • JVPincreasedwithdominant“x”descent
• arterialpulsenormaltodecreasedvolume,decreasedpulsepressure
• auscultation:distantheartsounds±rub
• Ewart’ssign
Investigations
• ECG:lowvoltage,flatTwaves,electricalalternans(classic,butnotsensitivetoexcludeeffusion)
■ be cautious in diagnosing STEMI in a patient with pericarditis and an effusion - antiplatelets may
precipitate hemorrhagic effusion
• CXR:cardiomegaly,roundedcardiaccontour
• ER:bedsideultrasoundwithsubxiphoidviewshowingfluidinpericardialsac
• Echo(procedureofchoice):fluidinpericardialsac
• pericardiocentesis:definitivemethodofdeterminingtransudatevs.exudate,identifyinfectiousagents,
Ewart’s Sign
Bronchial breathing and dullness to percussion at the lower angle of the left scapula in pericardial effusion due to effusion compressing left lower lobe of lung
neoplastic involvement