Download siegel 11-09 updated(pericarditis)

Pericardial Disease:
Selected Highlights
Residents’ Noon Conference
11/12/2009
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)

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)

Pericardial disease:
Differential Diagnosis, cont.
Drugs
A. Procainamide, isoniazid, or hydralazine as part of druginduced 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)

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)

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).
Pulsus Paradoxus Exam
How to perform and interpret the
pulsus paradoxus examination
 The most important learning goal of
this conference

Is Pulsus Present?
Decrease in systolic BP of
12mmHg or more
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

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

NEJM paradoxus tracing
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

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)
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.
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

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)
Severe Asthma:
Pulsus Without Tamponade
Pulsus
severity
Sensitivity Specificity
%
%
Positive
LR
Negative
LR
>10mmHg
52-68
69-92
2.7
0.5
>20mmHg
19-39
92-100
8.2
0.8
>25mmHg
16
99
22.6
0.8
McGee, Steven. Evidence-Based Physical Diagnosis.
Philadelphia: Elsevier, 2001.
What is the paradox?
Finding first described
in 1873
 Sphygmomanometer
invented 1881

Adolph Kussmaul
1822-1902
Malignant Thymoma, RV failure,
Pericardial Tamponade
CXR