CH. 68, PERICARDIAL AND MYOCARDIAL DISEASE

PERICARDITIS BASICS

100

UP TO THIS AMOUNT OF FLUID IS NORMALLY CONTAINED IN THE PERICARDIAL SPACE

35 ML

200

CHEST PAIN, PERICARDIAL FRICTION RUB, EKG ABNORMALITIES ARE CLASSIC SYMPTOMS OF THIS 

PERICARDITIS

300

PERICARDITIS CHEST PAIN VARIES WITH POSITION, AND IS TYPICALLY RELIEVED BY ____ AND WORSENED BY ____

SITTING FORWARD

LYING DOWN, DEEP INSPIRATION, SWALLOWING

PERICARDIAL PAIN USUALLY RETROSTERNAL, CAN RADIATE TO TRAPEZIUS, CAUSE ISOLATED SHOULDER PAIN, MAY HAVE DIAPHRAGMATIC PAIN

400

THIS IS THE "HALLMARK" PHYSICAL EXAM FINDING OF PERICARDITIS AND IS BEST HEARD WITH THE PATIENT IN THIS POSITION

PERICARDIAL FRICTION RUB

LEANING FORWARD IN FULL EXPIRATION

500

THIS IS THE MOST RELIABLE DIAGNOSTIC TOOL FOR PERICARDITIS

EKG

600

STEMI

700

DIFFUSE ST ELEVATION IN LEADS I, II, III, AVL, AVF, V2 - V6

ST DEPRESSION IN AVR, V1

CONCURRENT PR DEPRESSION

800

THIS EKG FINDING IS NOT SEEN IN THE ACUTE PHASE OF PERICARDITIS, BUT MAY BECOME PERMANENT ONCE PERICARDITIS RESOLVES

T WAVE INVERSION

YOU WILL ALSO NOT SEE Q WAVES ASSOCIATED WITH PERICARDITIS

900

TRUE/FALSE, VENTRICULAR DYSRHYTHMIAS ARE COMMON IN PERICARDIAL DISEASE

FALSE, THEY ARE RARE

IF DYSRHYTHMIAS ARE PRESENT THEN CONSIDER CONCOMITANT MYOCARDITIS OR ANOTHER CARDIAC DISEASE

1000

TRUE/FALSE, A NORMAL ECHOCARDIOGRAM CANNOT BE USED TO EXCLUDE PERICARDITIS

TRUE

ECHO MAY APPEAR NORMAL WITHOUT AN EFFUSION

1100

NAME 5 CAUSES OF PERICARDITIS

INFECTIOUS - VIRAL, BACTERIAL, FUNGAL, PARASITE, RICKETTSIA

POSTINJURY - TRAUMA, SURGERY, MI, RADIATION

METABOLIC - UREMIA, MEDICATION

SYSTEMIC DISEASE - RA, SLE, SARCOIDOSIS, SCLERODERMA, DERMATOMYOSITIS, AMYLOIDOSIS

TUMORS

AORTIC DISSECTION

1200

THIS IS THE TREATMENT OF CHOICE

NSAIDS

IBUPROFEN FOR 1 WEEK

IF INEFFECTIVE TRY ANOTHER NSAID - INDOMETHACIN, NAPROXEN

CONSIDER COLCHICINE FOR RECURRENT EPISODES

STEROIDS ARE SECOND LINE, USED FOR PEOPLE WHO CAN'T TAKE NSAIDs OR WHO ARE ON ANTICOAGULANTS

1300

TRUE/FALSE, 60% WILL HAVE COMPLETE RECOVERY IN 1 WEEK, ALMOST 80% HAVE COMPLETE RECOVERY WITHIN 3 WEEKS

TRUE

MORE PERICARDITIS

100

IN A DIALYSIS PATIENT, CARDIAC ENLARGEMENT ON CXR IN THE ABSENCE OF SIGNS OF VOLUME OVERLOAD OR CHF SHOULD PROMPT CONSIDERATION OF ____

PERICARDIAL EFFUSION

UREMIC PERICARDITIS WILL PRESENT WITH CHEST PAIN, UNEXPLAINED FEVER, POSSIBLY COARSE FRICTION RUB

UREMIC PERICARDIAL EFFUSIONS ARE AMONG MOST COMMON CAUSES OF CARDIAC TAMPONADE - OFTEN LOCULATED AND HARD TO DRAIN

TREATMENT FOR UREMIC PERICARDITIS IS?

200

FEVER, PLEURITIS, LEUKOCYTOSIS, PERICARDIAL FRICTION RUB, CXR SHOWING NEW PERICARDIAL EFFUSION OR PLEURAL EFFUSION IN POST-MI PATIENT IS CONCERNING FOR ____

DRESSLER'S SYNDROME OR POST-MI PERICARDITIS

OCCURS 2-8 WEEKS POST-MI

MAY OCCUR WITH PULMONARY EMBOLUS

RISK OF HEMORRHAGE WITH ANTICOAGULATION

TREATED WITH NSAIDS

300

TRUE/FALSE, PERICARDITIS MAY OCCUR AFTER CHEST TRAUMA NOT INVOLVING THE HEART OR PERICARDIUM

TRUE

TYPICALLY OCCURS 4-12 DAYS AFTER INJURY

400

TRUE/FALSE, HEPATOCELLULAR CARCINOMA IS A COMMON CAUSE OF NEOPLASTIC PERICARDIAL DISEASE

FALSE

LUNG CANCER, BREAST CANCER, LYMPHOMA, LEUKEMIA

MALIGNANT EFFUSIONS MAY CAUSE TAMPONADE IN LATE DISEASE PHASE, BUT PATIENT'S QUALITY OF LIFE MAY BE IMPROVED IF TREATED PROMPTLY

500

CORTICOSTEROID THERAPY IS THE TREATMENT OF CHOICE FOR PERICARDITIS IN THIS CATEGORY OF DISEASE

AUTOIMMINUE DISORDERS

1/3 OF PEOPLE WITH RA WILL DEVELOP PERICARDITIS WITHIN 3 YEARS OF RA DIAGNOSIS 

MOST AUTOIMMUNE DISORDERS MAY LEAD TO PERICARDITIS 

600

____ AND ____ CAUSES OF PERICARDITIS CAN COEXIST

VIRAL AND BACTERIAL

VARICELLA-ZOSTER SUPER-INFEFECTED WITH STAPH AUREUS FOR EXAMPLE, MORE COMMON IN CHILDREN

700

A CCMH HOSPITALIST BOUNCEBACK ARRIVES TO THE DREWRY FAMILY EMERGENCY CENTER 1 DAY AFTER BEING DISCHARGED FOLLOWING TREATMENT FOR SEPSIS DUE TO PNEUMONIA. THEY ARE A CIRRHOTIC DIALYSIS PATIENT WITH CHF AND DIABETES WHO ARE ALSO ON AN IMMUNOLOGIC FOR CROHN'S DISEASE. THEY COMPLAIN OF FEVER, DYSPNEA AND CHEST PAIN. THEY HAVE A PERICARDIAL EFFUSION ON BEDSIDE US. WHAT TYPE OF PERICARDITIS SHOULD BE CONSIDERED?

PRURULENT PERICARDITIS

MOST COMMON PRESENTATION IS HOSPITALIZED PATIENT WITH SEVERE UNDERLYING DISEASE WHO INITIALLY IMPROVES AFTER TREATMENT OF PRIMARY INFECTIOUS PROCESS BUT LATER DEVELOPS FEVER, DYSPNEA AND CHEST PAIN

ASSOCIATED WITH HIGH MORTALITY

800

A 30 YEAR OLD SOUTH AFRICAN EXPAT WHO HAD BEEN A VAGRANT LIVING ON THE STREETS OF JOHANNESBURG MAKES IT TO THE DREWRY FAMILY EMERGENCY CENTER AT CCMH. HE PRESENTS WITH CHEST PAIN, FEVER AND SHOB. HIS CXR SHOWS AN ENLARGED CARDIAC SILHOUETTE W/O PULMONARY INFILTRATES. WHAT SHOULD YOU BE WORRIED ABOUT AS THE CAUSE OF HIS PERICARDITIS?

TUBERCULOSIS

WHAT ELSE SHOULD HE BE TESTED FOR?

900

TRUE/FALSE, TENSION PNEUMOPERICARDIUM MANIFESTS WITH CLINICAL FINDINGS OF ACUTE CARDIAC TAMPONADE

TRUE

AFTER YOU HAVE EXCLUDED ALL OTHER LIFE THREATENING INJURIES/COMPLICATIONS CAN YOU DISCHARGE SOMEONE WITH UNCOMPLICATED SPONTANEOUS PNEUMOPERICARDIUM?

1000

SIGNS/SYMPTOMS OF CONSTRICTIVE PERICARDITIS ARE THE SAME AS THOSE SEEN IN ____

CHF

DYPSNEA, FATIGUE, WEIGHT GAIN MC COMPLAINTS

CONSTRICTIVE PERICARDITIS MAY BE SEEN AS LATE SEQUELA OF ACUTE PERICARDITIS FROM ANY CAUSE

INCREASING IN INCIDENCE DUE TO INCREASED SURVIVAL OF PATIENTS WITH CKD

PERICARDIAL EFFUSIONS

100

NAME 3 CAUSES OF PERICARDIAL EFFUSION

VIRAL OR IDIOPATHIC PERICARDITIS, MALIGNANCY, UREMIA, TRAUMA, RADIATION THERAPY

200

A MINIMUM OF ____ ML OF FLUID IS NECESSARY TO SEE A PERICARDIAL EFFUSION ON CXR

250 ML

WHAT IS THE DIAGNOSTIC MODALITY OF CHOICE FOR PERICARDIAL EFFUSION?

300

____ IS THE MOST IMPORTANT FACTOR IN THE DEVELOPMENT OF CARDIAC TAMPONADE

RATE OF FLUID ACCUMULATION

AS LITTLE AS 150 ML OF FLUID MAY CAUSE TAMPONADE

3 STAGES IN DEVELOPMENT OF TAMPONADE

1. FLUID FILLS RECESSES OF PARIETAL PERICARDIUM

2. FLUID ACCUMULATES FASTER THAN PARIETAL PERICARDIUM'S ABILITY TO STRETCH

3. FLUID ACCUMULATES FASTER THAN BODY'S ABILITY TO INCREASE BLOOD VOLUME TO SUPPORT RV FILLING PRESSURE

THIS ALL LEADS TO INCREASED PERICARDIAL PRESSURE, CAUSING DECREASED VENTRICULAR COMPLIANCE AND DECREASED BLOOD FLOW INTO HEART

WHAT IS THE HEART'S COMPENSATORY MECHANISM IN TAMPONADE?

400

TRUE/FALSE, HYPOTENSION, DISTENDED NECK VEINS AND MUFFLED HEART SOUNDS WILL ALWAYS BE PRESENT WITH TAMPONADE

FALSE

MAY BE ABSENT IF TAMPONADE DEVELOPS QUICKLY

WHAT IS THIS TRIAD CALLED?

500

ELECTRICAL ALTERNANS

600

____ IS THE TREATMENT OF CHOICE FOR CARDIAC TAMPONADE

PERCIARDIOCENTESIS/PERICARDIAL WINDOW

WHILE YOU PREP TO PERFORM A PERICARDIOCENTESIS THE PATIENT SHOULD BE RECEIVING ____ IN THE MEANTIME

MYOCARDITIS

100

____ IS THE MOST COMMON PRESENTING COMPLAINT FOR MYOCARDITIS IN CHILDREN

DYSPNEA

ADULTS WILL HAVE DYSPNEA ALONG WITH CHEST PAIN AND POSSIBLY DYSRHYTHMIAS

CHILDREN MAY HAVE GRUNTING AND/OR RETRACTIONS ON EXAM WITH CLEAR LUNG SOUNDS

200

TRUE/FALSE, TACHYCARDIA DISPROPORTIONATE TO TEMP OR APPARENT TOXICITY IS A SPECIFIC FINDING

FALSE

EITHER ONE OF THESE MAY BE THE ONLY FINDING ON EXAM, BUT THEY ARE NON-SPECIFIC

300

TRUE/FALSE, INFANTS OFTEN HAVE A FULMINANT SYNDROME CHARACTERIZED BY FEVER, CYANOSIS, RESPIRATORY DISTRESS, TACHYCARDIA, CARDIAC FAILURE

TRUE

400

NAME 2 EKG CHANGES COMMONLY ASSOCIATED

SINUS TACHYCARDIA, WIDE QRS, LOW VOLTAGE

PROLONGED QT, AV BLOCK, ACUTE MI PATTERN ALL POSSIBLE BUT LESS COMMON

EKG CHANGES MAY EXTEND BEYOND THE DISTRIBUTION OF A SINGLE CORONARY ARTERY

500

A 35 YEAR OLD MARATHON RUNNER WITH NO MEDICAL HISTORY PRESENTING WITH NEW ONSET CHF SYMPTOMS SHOULD PROMPT CONSIDERATION FOR ____ AS A CAUSE

MYOCARDITIS

CONSIDER IN YOUNG, HEALTHY PATIENTS WITH SIGNS OF NEW ONSET CHF OR DYSRHYTHMIAS 

600

TRUE/FALSE, STABLE PATIENTS WITH SUSPECTED MYOCARDITIS SHOULD BE DISCHARGED HOME

FALSE

ADMIT FOR MONITORING AND FURTHER WORKUP

700

A 36 YEAR OLD HONDURAN MIGRANT FEMALE PRESENTS TO THE DREWRY FAMILY EMERGENCY CENTER WITH COMPLAINTS OF SYNCOPE, CHEST PAIN AND FEVER. ON EXAM YOU NOTICE UNILATERAL PERIORBITAL EDEMA. SHE HAS MULTIPLE PVC'S ON HER EKG. WHILE ON THE MONITOR SHE HAS SEVERAL RUNS OF NON-SUSTAINED VTACH. YOU SHOULD CONSIDER THIS AS THE SOURCE OF HER SYMPTOMS. 

CHAGAS' DISEASE

CAUSED BY TRYPANOSOMA CRUZI

SYSTEMIC SYMPTOMS INCLUDE FEVER, HEPATOSPLENOMEGALY, UNILATERAL PERIORBITAL EDEMA, EMBOLIC EPISODES, HEART FAILURE, CONDUCTION ABNORMALITIES, PVC'S, ST AND T WAVE ABNORMALITIES

V TACH IS COMMON AND PRE-SYNCOPE/SYNCOPE OCCURS IN ALMOST 2/3 OF PATIENTS

800

A 55 YEAR OLD MEXICAN MIGRANT ARRIVES TO THE DREWRY FAMILY EMERGENCY CENTER COMPLAINING OF CHEST PAIN AND DYSPNEA. AN INTERN GOES IN TO SEE HIM. AFTER SPENDING ALMOST HALF AN HOUR IN THE ROOM GETTING A THOROUGH HISTORY (IE, SMOKING PACK YEARS, LAST COLONSCOPY, ETC.) THEY FIND OUT HE HAS HAD RECENT FEVERS, MYALGIAS, NECK STIFFNESS, AND SWELLING AROUND HIS EYES. BECAUSE DR. INTERN WAS SO THOROUGH IN THEIR HISTORY TAKING THEY ALSO FIND OUT THE PATIENT WAS A PIG FARMER UNTIL RECENTLY. WHAT IS THE MOST LIKELY SOURCE OF HIS SYMPTOMS?

TRICHINOSIS

CARDIAC MANIFESTATIONS INCLUDE CHEST PAIN, DYSPNEA, CARDIOMEGALY, DYSRHYTHMIAS AND CHF

900

WHAT CARDIAC SCREENING TEST IS RECOMMENDED FOR A PATIENT WHO HAS HAD THIS RASH AND WHAT WOULD BE THE MOST COMMON ABNORMALITY SEEN?

EKG 

MOST COMMON CARDIAC COMPLICATION IS CONDUCTION DELAY, USUALLY AT THE AV NODE (AV BLOCK)

1000

DYSFUNCTION OF THIS HEART VENTRICLE IS SEEN IN 20% OF ADULT AIDS PATIENTS

LEFT VENTRICULAR DYSFUNCTION

CARDIAC INVOLVEMENT INCREASES AS DISEASE WORSENS, HIV TREATMENTS MAY CAUSE CARDIOTOXICITY, MANY OPPORTUNISTIC INFECTIONS (M. PNEUMONIA, TOXOPLASMA, CHAMLYDIA PNEUMONIAE) CAN CAUSE MYOCARDITIS

CARDIOMYOPATHIES

100

THIS CARDIOMYOPATHY WILL PRESENT WITH HEART FAILURE SYMPTOMS IN BOTH ADULTS AND CHILDREN

DILATED CARDIOMYOPATHY

ISCHEMIC CARDIOMYOPATHY SECONDARY TO CAD IS MC NON-GENETIC CAUSE OF DCM

200

A 19 YEAR OLD MALE SUDDENLY DROPS DEAD WHILE PLAYING BASKETBALL. THE PATIENT LIKELY HAD THIS AUTOSOMAL DOMINANT CONDITION AND DIED FROM THIS TYPE OF ARRHYTHMIA 

VENTRICULAR TACHYARRHYTHMIAS - V FIB, V TACH

HYPERTROPHIC CARDIOMYOPATHY

ASSOCIATED WITH A LOUD CRESCENDO-DECRESCENDO MURMUR WHICH WILL DECREASE WITH INCREASES IN PRELOAD OR AFTERLOAD

ASIDE FROM SUDDEN DEATH DURING EXERTION, 90% WILL COMPLAIN OF SHORTNESS OF BREATH, OTHER SYMPTOMS INCLUDE ORTHOPNEA, EDEMA CHEST PAIN, SYNCOPE, NEAR-SYNCOPE, PALPITATIONS

300

• Left ventricular hypertrophy with increased precordial voltages and non-specific ST segment and T-wave abnormalities
• Deep, narrow (“dagger-like”) Q waves in lateral (I, aVL, V5-6) +/- inferior (II, III, aVF) leads

WOULD YOU GIVE NITRO TO THIS PATIENT IF THEY PRESENTED WITH CHEST PAIN? WHY OR WHY NOT?

400

SYMPTOMS OF THIS CARDIOMYOPATHY INCLUDE EXERCISE INTOLERANCE, PERIPHERAL EDEMA, PULMONARY EDEMA, S3 AND S4 GALLOPS

RESTRICTIVE CARDIOMYOPATHY

CAUSES DIASTOLIC DYSFUNCTION DUE TO RESTRICTED VENTRICULAR FILLING

500

A  FEMALE WHO IS 8 MONTHS PREGNANT PRESENTS WITH SHORTNESS OF BREATH, PERIPHERAL EDEMA AND HAS PULM EDEMA ON CXR. THEY MOST LIKELY HAVE THIS

PERIPARTUM CARDIOMYOPATHY

OCCURS DURING LAST 3 MONTHS OF PREGNANCY AND UP TO 5 MONTHS POSTPARTUM

600

A 35 YO MALE PRESENTS WITH NEAR SYNCOPE AND PALPITATIONS ON AND OFF FOR 2 DAYS. HE HAS NO PMH. HE IS ESTRANGED FROM HIS FAMILY BECAUSE HIS PARENTS TOOK AWAY HIS STASH OF NUDEY MAGS AND CIGARETTES ONCE IN HIGH SCHOOL, BUT THINKS HE HAD 1 OR 2 RELATIVES DIE FROM SOME SORT OF EARLY CARDIAC DEATH. WHAT DISORDER DOES HE HAVE AND WHAT IS HIS CURRENT RHYTHM?

HCM WITH AFIB 

HIS INITIAL BP IS 140/85. WHAT DO YOU WANT TO DO?

LET'S SAY HIS PRESSURE DROPPED TO 80/40 WHILE YOU WERE SOILING YOURSELF TRYING TO MAKE A DECISION?

YOU FINALLY MADE A DECISION, BUT HE'S PERSISTENTLY HYPOTENSIVE DESPITE RHYTHM IMPROVEMENT (YOU'VE NOW COMPLETELY EVACUATED YOUR BLADDER AND BOWELS AND ARE ON THE VERGE OF A PSEUDOSEIZURE). WHAT PRESSOR WOULD BE PREFERRED?

700

A 28 FEMALE WHO IS CURRENTLY 37 WEEKS WITH CHILD PRESENTS WITH SHORTNESS OF BREATH, CHEST PAIN, ORTHOPNEA AND LE SWELLING WORSENING FOR THE PAST 4 DAYS. SHE IS EDEMATOUS AND HAS RALES ON EXAM. BP IS 180/95. VITALS ARE OTHERWISE OKAY. GIVE 3 DIFFERENTIALS. 

PERIPARTUM CARDIOMYOPATHY, PRE-ECLAMPSIA, PE, MYOCARDIAL ISCHEMIA

HOW WOULD YOU TREAT THIS PATIENT?

WHAT MEDICATION COULD YOU GIVE TO BRING HER PRESSURE DOWN? WILL IT HELP WITH PRELOAD OR AFTERLOAD?

800

A 75 YEAR OLD FEMALE WITH A HX OF TOBACCO AND ETOH ABUSE PRESENTS WITH CHEST PAIN, DYSPNEA AND PALPITATIONS. SHE TELLS YOU HER HUSBAND OF 50 YEARS RECENTLY DIED AND SHE HAD TO SELL HER HOUSE TO PAY GAMBLING DEBTS. THIS IS HER EKG. WHAT DO YOU DO?

ACTIVATE THE CATH LAB AFTER YOUR ASTUTE RECOGNITION OF A STEMI. 

THEIR TROPONIN AND BNP ARE ELEVATED.

THE CARDIOLOGIST CALLS YOU AFTER THEY'VE DONE THE CATH TO TELL YOU THERE WAS NOT SIGNIFICANT CAD. THEN HE SENDS YOU THIS PIC AND WANTS YOU TO TELL THEM WHAT THEY HAVE. 

900

A 30 YEAR OLD MARATHON RUNNER NAMED GIOVANNI LOMBARDI PRESENTS AFTER A SYNCOPAL EPISODE DURING A RACE. HE DEVELOPS PALPITATIONS AFTER COMING TO, AND COMES TO THE ED. HE LOSES CONSCIOUSNESS AS THEY GET HIM ON THE MONITOR. THIS IS WHAT YOU SEE. WHAT IS THIS AND WHAT DO YOU DO?

VTACH. CARDIOVERSION. 

CARDIOVERSION IS SUCCESSFUL (GOOD JOB). HE IS NOW AWAKE AND TALKING TO YOU. THIS IS HIS REPEAT EKG.

WHAT DO YOU SEE? WHAT DOES HE HAVE?