Term
| What happens to the RV in response to increased LV thickness from endocardial/myocardial/pericardial thickening? |
|
Definition
RV fills the LV
So RV generates more pressure (above 10 mmhg), which increases pulmonary venous pressure (PVHTN)
- PRVHTN can cause dyspnea, because dilated capillaries (constricted arterioles don't slow it down) allow fluid to be pushed through.. |
|
|
Term
| What happens do venous pressure during RVH? |
|
Definition
It takes more pressure to fill a stiffer ventricle, so systemic venous pressure is increased (above 5mm hg) via retention of sodium and water.
This causes systemic congestion with
1) Elevated JVP
2) Enlarged liver
3) Edema of feet and ascites |
|
|
Term
| What are the 3 presenting features of Systemic venous hypertension? |
|
Definition
1) JVD
2) Enlarged liver
3) Edema of feet and ascites |
|
|
Term
| Why might a patient with venous hypertension develops low CO and how might it present acutely/chronically? |
|
Definition
When RVH occurs, SVP is ramped up to supply the ventricle.
If SVP cannot increase adequately to maintain SV and CO, CO drops.
1) Chronically- Fatigue
2) Acutely- Hypotension, low PP, thready pulse, tachycardia, sweaty, cold and clammy, renal insufficiency |
|
|
Term
| Why might pulmonary and systemic venous pressure be elevated and equal? |
|
Definition
| If pericardial sack is thickened with fibrosis or fluid, the pressure required to fill the RV and LV will be elevated and equal (instead of being 5 mmhg for the right and 10 mmhg for the left) |
|
|
Term
| What are the 3 primary pericardial diseases? |
|
Definition
1) Acute pericarditis
- Vasodilation (transudation of fluid), Increased vascular permeability (protein leakage), Leukocyte exudation (PMN and mononuclear cells)
2) Pericardial effusion
3) Constrictive pericarditis |
|
|
Term
| What pathophysiological changes occur in acute pericarditis? |
|
Definition
1) Vasodilation- transudation of fluid
2) Increases vascular permeability- Protein leakage
3) Leukocyte exudation- PMNs and mononuclear cells
Ca be serious, fibrinous, hemorrhagic, suppurative and chylous. |
|
|
Term
A patient presents with pain on inspiration and lying down that is relieved by sitting up and leaning forward.
They also have a fever, a friction rub and their EKG shows ST elevation with concavity upwards and PR segment depression.
How do you treat? |
|
Definition
Acute Pericarditis
1) Pre-load-dependent pain
2) Fever
3) Friction rub
4) ST elevation/PR depression
- Treat pain with Aspirin and other NSAIDs
- Steroids for recurring pericarditis
- Antibiotics for purulent
- TB- Multi drug therapy
- Neoplastic: Radiation or Chemo |
|
|
Term
| What is the pathophysiology of Pericardial effusion? |
|
Definition
1) Pericardial fluid increases stiffness of ventricles (stiffness increase is proportional to rapidity and quantity)
2) Venous pressures distend atria and ventricles with high pressure (tampenade), which also distends the fluid filled pericardium. |
|
|
Term
| What hemodynamic changes occur in pericardial effusion? |
|
Definition
1) SVP and PVP are elevated and equal
2) RV diastolic pressure is elevated to >1/3 of RV systolic pressure
3) Early diastolic dip in RV pressure tracing and 'Y' descend in RA pressure tracing is absent (diastolic collapse during early diastolic filling). |
|
|
Term
| What is Pulsus paradoxus and when do you see it? |
|
Definition
Arterial systolic pressure decreases >10 mm hg on inspiration
1) During inspiration, IT pressure drops with fall in pulmonary venous pressure. Since PVP< SVP, LV fills less than RV. Therefore, arterial systolic pressure decreases with decreased LV SV.
2) In Pulsus Paradoxus, the decrease in systemic arterial pressure is much greater than would be expected, and it indicates Pericardial Effusion and if > 20, may indicate Tampenade. |
|
|
Term
A patient presents with elevated venous pressure. You notice JVD, hypotension and muffled heart sounds. You also determine a drop in systolic arterial pressure >10 mg upon inspiration.
What do you see on Echo and EKG? |
|
Definition
The patient has pericardial effusion due to tampenade (Beck's triad). The pulsus paradoxis is characteristic.
Echo- Large effusion
- Absence of inspiratory collapse of IVC
- RA/RV collapse
- Inspiratory decrease in Mitral valve flow velocity >25%
EKG
- Low amplitude and electrical alternans |
|
|
Term
| What are the appropriate treatments for cardiac tamponade? |
|
Definition
1) Pericardiocentisis
2) Pericardial window
3) Balloon pericardiotomy
4) Surgical removal of part of all pericardium
EMERGENCY
1) IV fluids
2) Isoproternol |
|
|
Term
| What drugs should be AVOIDED in in a patient with JVD, hypotension and muffled heart sounds? |
|
Definition
In tampenade, avoid volume depletion or bradycardia.
1) Diuretics
2) Beta blockers
3) Calcium channel blockers
4) Vasoconstrictors |
|
|
Term
| Why do you see increased venous pressures in constrictive pericarditis (e.g. what is the pathophysiology?)? |
|
Definition
| Thickened, fibrous pericardium becomes adherent to atria and ventricles, increasing stiffness. |
|
|
Term
A patient presents with elevated JVP, shortness of breath, fatigue and a pericardial knock on physical eam.
On EKG, you see evidence of A fib and liver enzymes are elevated.
How do you treat? |
|
Definition
Clinical features of Constrictive Pericarditis include 1) Elevated JVP, 2) PVP (dyspnea), 3) low CO (fatigue) and a 4) pericardial knock
A fib is found in 50% of cases and liver enzymes are elevated due to congestion of liver.
Treat with Pericardiectomy
***Diuresis will cause decrease in CO*** |
|
|
Term
| Why might you see elevated JVP in constrictive pericarditis? |
|
Definition
1) Kussmaul sign: Apparent increase in venous pressure due to lack of inspiratory fall in venous pressure (mean) with exaggeration of venous waves.
2) Edema
3) Ascites |
|
|
Term
| What hemodynamic changes take place in pericarditis? |
|
Definition
1) Systemic and pulmonary venous pressures are elevated and equal (like in pericardial effusion).
2) RV diastolic pressure is >1/3 of RV systolic pressure (like in pericardial effusion)
3) Early diastolic dip in RV pressure and Y descent in RA is PRESERVED. |
|
|
Term
| How can you tell between constrictive pericarditis and pericardial effusion based upon hemodynamics? |
|
Definition
Both have elevated and equal systemic and pulmonary venous pressures, as well as increased RV diastolic pressure (>1/3 of RV systolic pressure).
1) Constrictive pericarditis will have PRESERVED Y descent (diastolic collapse in early diastolic filling) and absent Pulsus pardoxus (decrease in systemic arterial pressure on inspiration > 10 mg)
2) In Cardiac tampenade/pericardial effusion, y descent is ABSENT, and you see Pulsus pardoxus. |
|
|
Term
| How can you tell between Restrictive Cardiomyopathy and Constrictive pericarditis? |
|
Definition
1) Restrictive
- Amyloidosis or hemochromatosis
- LVEDP - RVEDP > 5mmhg
- normal pericardium
2) Constrictive
- No extra cardiac manifestations
- LVEDP= RVEDP
- thickened pericardium |
|
|
