questions 14


Topic updated on 06/16/17 10:38am

  • A 63-year-old male presents with severe chest pain that is alleviated by leaning forward. Physical exam reveals CVP and a friction rub best heard when the patient leans forward. ECG shows ST elevation in all leads and PR depression in the precordial leads.
  • Inflammation of the pericardial sac resulting from acute or chronic pericardial insults
    • often leads to pericardial effusion
    • can compromise cardiac output via
      • tamponade
      • constrictive pericarditis
  • Etiology  
    • most commonly idiopathic
    • other known causes include
      • SLE
      • uremia
      • viral infection
      • TB
      • RA
      • neoplasms
      • drugs
      • radiation
      • scleroderma
    • may also occur following
      • MI
      • open heart surgery 
      • radiotherapy
  • The normal pericardium consists of two layers
    • a fibrous outer layer
      • the outer fibrous pericardium produces one of the most echo-producing areas of the heart.
    • serous inner layer
      • the serous layer is a closed sac with the visceral component lining the epicardium and the parietal component lining the fibrous outer layer.
  • Symptoms
    • dyspnea
    • cough
    • fever
      • often following URI
    • pleuritic chest pain
      • worse when the patient is supine and during inspiration
      • alleviated when the patient leans forward
  • Physical exam
    • pericardial friction rub 
      • best heard with patient leaning forward
    • elevated JVP
    • pulsus paradoxus
      • raises concern for tamponade
  • Diagnosis is clinical
  • Echocardiography
    • is confirmatory
    • may demonstrate pericardial thickening or effusion
  • EKG 
    • low voltage overall
    • PR depression in the precordial leads 
    • diffuse ST segment elevation
    • T-wave inversions
      • classic EKG changes are mostly absent in uremic pericarditis 
  • CXR
    • primarily to rule out pneumonia
    • may show signs of pericardial effusion
    • constrictive pericarditis may show signs of pericardial calcifications 
  • Cardiac tamponade, hemopericardium, heart failure, MI, pneumonia, pneumothorax
  • Nonoperative
    • observation & treatment of underlying cause
      • indications
        • in cases of asymptomatic or small pericardial effusion
      • medical treatment of underlying condition
        • NSAIDS  
          • for viral pericarditis
        • steroids and immunosuppressants
          • for SLE
          • avoid immediately following MI to protect from ventricular wall rupture
        • dialysis  
          • for uremia
        • aspirin 
          • for post-MI pericarditis   
    • pericardiocentesis
      • indications
        • required for large effusions & cardiac tamponade
  • Operative
    • pericardiectomy
      • reserved for recurrent disease
Prognosis, Prevention, and Complications
  • Prognosis
    • depends highly on etiology of disease
    • most cases resolve spontaneously
  • Prevention
    • onset is unpredictable in most cases
    • early intervention for symptomatic relief
    • large effusions might require continuous drainage to prevent more severe sequelae
  • Complications
    • effusion can lead to constrictive pericarditis or tamponade
      • potentially resulting in death


Qbank (6 Questions)

(M3.CV.32) A 59-year-old female presents to the emergency department with severe chest pain and shortness of breath. She reports that she was walking in her house when the pain began and it worsened when she laid down to go to bed later in the evening. She experiences relief of the chest pain when she sits down and leans forward with her chest over her knees. She was discharged from the hospital earlier today after suffering from an ST-elevation myocardial infarction 2 days ago that was successfully treated with coronary revascularization. Her past medical history is significant for hypertension and rheumatoid arthritis. Vital signs are as follows: T 37.0 C, HR 82, BP 138/80, RR 14, O2 Sat 99%. Physical examination is significant for a friction rub on cardiac auscultation and an estimated jugular venous pressure of 11 cm H2O. An electrocardiogram is obtained and shown in Figure A. An echocardiogram is obtained and reveals good contractile function of the heart with an ejection fraction of 60% as well as a pericardial effusion, shown in Figure B. A chest radiograph reveals a cardiac silhouette size within normal limits. Which of the following is the best management of this patient's condition? Topic Review Topic
FIGURES: A   B        

1. Reassurance and instruction to continue adherence to her cardiologist's recommendations
2. Administer high-dose aspirin
3. Initiate prednisone
4. Pursue emergent pericardial window
5. Admit for pericardiectomy

(M3.CV.57) A 46-year-old woman presents to the emergency department complaining of chest pain. She last felt well roughly two days ago when she began experiencing chest pain and low-grade fever, and since then these symptoms have persisted. She is otherwise healthy and takes no medications; she has never traveled outside of the United States. On examination, her vital signs are T 37.7, pulse 102 beats per minute, blood pressure 116/79, and O2 saturation 97% on room air. She is uncomfortable but otherwise well-appearing; cardiac exam reveals mild tachycardia, regular, with a scratching sound heard during systole. Examination is otherwise unrevealing. Which of the following is the most likely etiology for the patient's diagnosis? Topic Review Topic

1. Autoimmune
2. Tuberculosis
3. Malignancy
4. Bacterial infection
5. Idiopathic

(M3.CV.71) A 61-year-old male complains of chest pain two days after undergoing revascularization of his left anterior descending artery due to acute myocardial infarction (MI). The patient complains of severe chest pain that is worse upon inspiration and is relieved by sitting up and leaning forward. EKG findings are shown in Figure A. Echocardiography shows no evidence of tamponade. Which of the following is indicated in the treatment of this patient? Topic Review Topic
FIGURES: A          

1. Administer aspirin
2. Perform pericardiocentesis
3. Administer prednisone
4. Perform emergent cardiac catheterization
5. Administer clopidogrel

(M2.CV.44) A 68-year-old man presents to the emergency room complaining of chest pain. The pain is located on the left side of his chest, and is worse with deep breathing and better with leaning forward. His past medical history is significant for a myocardial infarction one year ago. He also has hypertension; paroxysmal atrial fibrillation; and type 2 diabetes mellitus complicated by retinopathy, peripheral neuropathy, and chronic renal insufficiency. His medications include metoprolol, simvastatin, lisinopril, coumadin, and insulin. His temperature is 37 C (98.6 F), blood pressure 140/82 mm Hg, pulse 88/min, and respiratory rate 16/min. On physical exam, he has an S4 heart sound and a friction rub. Jugular venous pressure, pulmonary auscultation, and abdominal exam are within normal limits. His electrocardiogram (EKG) is shown in Figure A, chest radiograph in Figure B, and echocardiogram in Figure C. Initial laboratory results are as follows:
Sodium 136 mEq/L, potassium 5.6 mEq/L, bicarbonate 16 mEq/L, BUN 74 mg/dL, creatinine 3.9 mg/dL, glucose 225 mg/dL.
Hemoglobin 9.4 g/dL, white blood cell count 7.3/µL, platelets 190,000/µL.

Which of the following is the most appropriate next step in management? Topic Review Topic
FIGURES: A   B   C      

1. Naproxen
2. Colchicine
3. Hemodialysis
4. Pericardiocentesis
5. Coronary angiography

(M2.CV.115) A 65-year-old male with a past medical history of a 2-vessel coronary bypass surgery six months ago presents with increasing abdominal girth, peripheral edema, and fatigue for the past two weeks. On physical exam, he is noted to have an increased jugular venous pressure (JVP) that increases with inspiration. A "knock" is ausculated. Which of the following is the most likely diagnosis: Topic Review Topic

1. Constrictive pericarditis
2. Interventricular septum perforation
3. Ventricular wall perforation
4. Viral pericarditis
5. A subacute right ventricular infarction

(M2.CV.140) A 48-year-old male with type I diabetes mellitus and end-stage renal disease currently on hemodialysis presents to the emergency department with dyspnea, cough and chest pain. He describes the pain as worse during inspiration and when he is lying on his back. A basic metabolic panel is remarkable for a BUN > 60 mg/dL. Which of the following would be expected during the evaluation of this patient? Topic Review Topic

1. Fever
2. Diffuse ST elevations on EKG
3. S4 cardiac murmur
4. Janeway lesions
5. Holosystolic heart murmur

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