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Pericardial Disease: Selected Highlights

Pericardial Disease: Selected Highlights. Residents’ Noon Conference 11/12/2009. Pericardial disease: Differential Diagnosis. Infections

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Pericardial Disease: Selected Highlights

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  1. Pericardial Disease: Selected Highlights Residents’ Noon Conference 11/12/2009

  2. Pericardial disease: Differential Diagnosis • Infections A. Viral - Coxsackievirus, Echovirus, Adenovirus, EBV, CMV, Influenza, Varicella, Rubella, HIV, Hepatitis B, Mumps, Parvovirus B19, Vaccina (smallpox vaccination) B. Bacterial - Staphylococcus, Streptococcus, Pneumococcus, Haemophilus, Neisseria (gonorrhoeae or meningitidis), Chlamydia (psittaci or trachomatis), Legionella, Tuberculosis, Salmonella, Lyme disease C. Mycoplasma D. Fungal - Histoplasmosis, Aspergillosis, Blastomycosis, Coccidiodomycosis, Actinomycosis, Nocardia, Candida E. Parasitic - Echinococcus, amebiasis, Toxoplasmosis F. Infective endocarditis with valve ring abscess (the first of five slides)

  3. Pericardial disease: Differential Diagnosis, cont. • Radiation • Neoplasm A. Metastatic - Lung or breast cancer, Hodgkin's disease, leukemia, melanoma B. Primary - rhabdomyosarcoma, teratoma, thymoma, fibroma, lipoma, leiomyoma, angioma C. Paraneoplastic • Cardiac A. Early infarction pericarditis B. Late postcardiac injury syndrome (Dressler's syndrome), also seen in other settings C. Myocarditis D. Dissecting aortic aneurysm (continued on next slide)

  4. Pericardial disease: Differential Diagnosis, cont. • Drugs A. Procainamide, isoniazid, or hydralazine as part of drug-induced lupus B. Other - cromolyn sodium, dantrolene, methysergide, anticoagulants, thrombolytics, phenytoin, penicillin, phenylbutazone, doxorubicin • Metabolic A. Hypothyroidism - primarily pericardial effusion B. Uremia C. Ovarian hyperstimulation syndrome (continued on next slide)

  5. Pericardial disease: Differential Diagnosis, cont. • Trauma A. Blunt B. Penetrating C. Iatrogenic - Catheter and pacemaker perforations, cardiopulmonary resuscitation, post-thoracic surgery • Autoimmune A. Rheumatic diseases - including lupus, rheumatoid arthritis, vasculitis, scleroderma, mixed connective disease B. Other - Wegener's granulomatosis, polyarteritis nodosa, sarcoidosis, inflammatory bowel disease (Crohn's, ulcerative colitis), Whipple's, giant cell arteritis, Behcet's disease (continued on next slide)

  6. Pericardial disease: Differential Diagnosis, cont. • Idiopathic In most case series, the majority of patients are not found to have an identifiable cause of pericardial disease. Frequently such cases are presumed to have a viral or autoimmune etiology. Adapted from Shabetai, R. Diseases of the pericardium. In: Hurst's The Heart, 8th ed, Schlant, RC, Alexander, RW, et al (Eds).

  7. Pulsus Paradoxus Exam • How to perform and interpret the pulsus paradoxus examination • The most important learning goal of this conference

  8. Is Pulsus Present?

  9. Decrease in systolic BP of 12mmHg or more

  10. Pulsus Paradoxus: Checklist • Make sure the heart rhythm is regular • Make sure respiration is quiet • Prepare the patient: Explain that the BP cuff will be inflated longer than usual • Do not attempt to assess patient’s respiration--focus on the BP cuff

  11. Pulsus Paradoxus Exam • Inflate cuff until no Korotkoff sounds audible • Deflate cuff to determine the highest pressure where any Korotkoff sounds are audible-This is the maximum possible systolic blood pressure

  12. NEJM paradoxus tracing

  13. Pulsus Paradoxus, cont. • Deflate cuff to the highest pressure where Korotkoff sounds are audible with EVERY heart beat • Subtract the maximal possible systolic BP from this number--this is the pulsus paradoxus • Document all the numbers in the electronic medical record

  14. Pulsus paradoxus • What is the sensitivity and specificity of a pulsus paradoxus greater than 10mmHg in detecting pericardial tamponade? • What about 12mmHg?(assuming that the patient has known pericardial effusion, a regular heart rate, and is being examined during quiet respiration)

  15. Pulsus paradoxus, cont. Pulsus paradoxus >12mmHg has a sensitivity of 98% and specificity of 85% to detect tamponade. Choosing a cutoff of 10mmHg worsens specificity without changing sensitivity significantly (most tamponade patients have pulsus > 20mmHg) Curtiss EI et. al. Pulsus Paradoxus: Definition and Relation to the Severity of Tamponade. An Heart J 115:391-398, 1998. Tamponade was defined as an improvement in cardiac output of 20% or more following pericardiocentesis.

  16. Differential Diagnosis of Pulsus without Tamponade: • Constrictive pericarditis • Asthma exacerbation (severe) • COPD exacerbation • Pregnancy/obesity • Right ventricular infarction • SVC syndrome • Pulmonary embolism (rare) • Atrioventricular dissociation

  17. Severe Acute Asthma: Pulsus Without Tamponade • Low sensitivity but high specificity finding for severe asthma • Severe: FEV1/FVC < 50%, FEV1 < 1L, peak flow < 200/min, and peak flow < 30% predicted (A peak flow meter is usually more useful in the clinical setting)

  18. Severe Asthma: Pulsus Without Tamponade McGee, Steven. Evidence-Based Physical Diagnosis. Philadelphia: Elsevier, 2001.

  19. What is the paradox? • Finding first described in 1873 • Sphygmomanometer invented 1881 Adolph Kussmaul 1822-1902

  20. CXR • Malignant Thymoma, RV failure, Pericardial Tamponade

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