Cardiology Intensive Board Review, 3th Edition

Chapter 13 - Pericardial Disease

Wael A. Jaber, Parag R. Patel

QUESTIONS

1.A 62-year-old man is admitted with chronic obstructive pulmonary disease (COPD) and mild left ventricular (LV) dysfunction (ejection fraction [EF] 45%) as well as symptomatic, recurrent atrial fibrillation (heart rate [HR] 120s to 150s) despite antiarrhythmic drug therapy and direct current cardioversion in the past. After rate control with intravenous (IV) β-blockers, the HR improves and the patient feels better. Given his recurrent atrial fibrillation despite optimal medical therapy, the patient is referred for radiofrequency ablation of atrial fibrillation (pulmonary vein isolation) procedure. The procedure is performed on anticoagulation (international normalized ratio >2.0) and is deemed a success, with no inducible atrial fibrillation at the end of the case. A small atrial septal defect (ASD) was noted with intracardiac echocardiography at the end of the case, with no other remarkable findings. That evening in the post-anesthesia care-unit (PACU), the patient is noted to be hypotensive and tachycardic with increasing dyspnea. There is a concern for cardiac tamponade; however, the arterial line does not show a significant respiratory variation of the blood pressure (BP) waveform (pulsus paradoxus). An echocardiogram is performed, demonstrating a large circumferential effusion and the patient is referred for urgent pericardiocentesis. Which of the following explains why the patient did not develop a pulsus on the arterial line, despite a large, hemodynamically significant pericardial effusion?

a.Presence of an ASD

b.Administration of excess IV fluid during the ablation

c.LV dysfunction

d.COPD

2.A 38-year-old patient with no prior medical history presents to the emergency room with 4 days of chest discomfort. He denies any recent trauma, fever, or use of anticoagulants. The pain is positional and the patient reports mild upper respiratory infection (URI) symptoms in the preceding week. Laboratory work is notable for elevated white blood cell count (neutrophil predominance) as well as elevated erythrocyte sedimentation rate (ESR)/high-sensitivity C-reactive protein (hsCRP); his troponin and other laboratory work is otherwise negative/normal. Electrocardiogram (ECG) is consistent with pericarditis. There is a low suspicion for acute coronary syndrome, and acute pericarditis is diagnosed with small effusion on the echocardiogram; the pain improves with analgesics. Which of the following regimens is the most appropriate therapy for this patient to treat the acute episode and maintain remission?

a.Ibuprofen 600 TID for 2 weeks followed by taper and colchicine 0.5 mg BID for 3 months

b.Aspirin 325 daily and colchicine 0.5 mg BID for 2 weeks followed by taper

c.Ibuprofen 400 BID and colchicine 0.5 mg BID for 2 weeks followed by no taper

d.Prednisone 10 mg daily and ibuprofen 600 TID for 3 months followed by no taper

3.A 62-year-old man with cardiac risk factors of tobacco use, hypertension, and diabetes mellitus returns for follow-up after late-presenting mid-left anterior descending artery (LAD) ST-elevation myocardial infarction (MI). He had an occluded mid-LAD, which was successfully aspirated and stented with a single drug-eluting stent; no significant disease elsewhere is noted. The next day he reports progressive chest discomfort and mild fever and has developed a two-component pericardial friction rub on physical examination. His ECG is concerning for pericarditis (Dressler syndrome) and an echo is performed showing no interval change from discharge other than the presence of a small pericardial effusion. Which of the following regimens would be the most appropriate therapy in this patient?

a.Aspirin 650 TID for 2 weeks with taper to 81 mg daily + colchicine 0.5 mg BID for 3 months

b.Aspirin 325 daily for 2 weeks, then taper to 81 mg daily + ibuprofen 600 mg TID for 3 months

c.Ibuprofen 600 mg TID for 2 weeks with taper + colchicine 0.5 mg BID for 3 months

d.Indomethacin 50 mg TID for 3 months as well as aspirin 650 mg TID for 3 months with taper to 81 mg

4.A 45-year-old male patient with a history of acute pericarditis now returns for outpatient follow-up with increasing dyspnea and lower extremity edema. The patient was seen and started on high-dose aspirin and colchicine (no nonsteroidal anti-inflammatory drugs [NSAIDs] due to allergy) and has not been able to taper for the past 6 months due to persistent low-level symptoms. He has an elevated jugular venous pulse without inspiratory decline, 2+ pedal edema, and congested liver without ascites, as well as a soft pericardial knock. Laboratory values are notable for mild transaminitis as well as elevated ESR/hsCRP. ECG is unremarkable and echo shows a small persistent pericardial effusion with tubular-shaped LV with normal function, along with diastolic bounce and conical-shaped right ventricle (RV) as well as plethoric inferior vena cava and respirophasic transmitral and trans-tricuspid variation all consistent with constrictive pericarditis. Which of the following would be the next most appropriate step in management?

a.Initiate steroid therapy (0.25 to 0.5 mg/kg/day) along with colchicine, and initiate PO diuretic

b.Admit for IV diuresis and transition to PO diuretic regimen after cardiac catheterization for constriction evaluation

c.Repeat echo in 2 to 3 months aspirin and colchicine at current doses

d.Surgical evaluation for pericardiectomy/stripping

5.A 39-year-old patient with no prior medical visits presents with cardiac tamponade and undergoes urgent pericardiocentesis. He is from sub-Saharan Africa and has never been seen by a physician before—reports feeling progressively ill for the past month and brought to the hospital after syncopal episode today. Fluid analysis is performed and listed below:

Gram stain: no gram-positive/gram-negative bacteria noted

Peripheral cell count: normal (peripheral cell count <10 × 109 cells/L)

Pericardial fluid differential (lymphocyte/neutrophil): >1.0 (monocytes present as well)

Protein: elevated

hsCRP: markedly elevated

Lactate dehydrogenase (LDH): elevated (>2.0 times peripheral LDH level)

Adenosine deaminase (ADA): >40 U/L

Interferon gamma: >50 pg/mL

Glucose: low

Culture and cytology/acid fast staining: pending

The most likely etiology for the effusion would be

a.tuberculous pericarditis.

b.endemic malignancy (i.e., Epstein-Barr virus–associated Burkitt’s) with metastatic spread.

c.malarial (Plasmodium vivax).

d.unable to determine—require pericardial biopsy to confirm.

6.A 47-year-old man with constrictive pericarditis is undergoing an echocardiogram for follow-up. The sonographer asks you to explain the difference between the annulus reversus and annulus paradoxus phenomena. Which of the following statements is correct?

a.Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities (E′ septal > E′ lateral) and annulus paradoxus refers to inverse correlation of E/E’ and LV end-diastolic pressure.

b.Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities (A′ septal > A′ lateral) and annulus paradoxus refers to inverse correlation of E/E′ and LV end-diastolic pressure.

c.Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities (E′ septal < E′ lateral) and annulus paradoxus refers to positive correlation of E/E′ and LV end-diastolic pressure.

d.Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities (A′ septal < A′ lateral) and annulus paradoxus refers to a positive correlation of E/E′ and LV end-diastolic pressure.

7.A 51-year-old male patient is admitted to the hospital with anasarca and progressive dyspnea and functional limitation. He has a prior history of coronary artery bypass grafting and post-pericardiotomy syndrome with relapsing pericarditis that has likely advanced to constrictive physiology (despite slow taper steroid therapy), given his presenting symptoms and physical examination findings. During the admission he is aggressively diuresed with IV diuretics with improvement in his renal and liver function, as well as symptom improvement (edema and dyspnea). He is unable to go for a magnetic resonance imaging (MRI) for further assessment (prior metallic implant in his spine for scoliosis) and his echocardiogram images are technically difficult due to his distorted spine and prior cardiac surgery.

He is referred for dual transducer cardiac catheterization for hemodynamic evaluation of right- and left-sided pressures as part of his diagnostic workup. The catheterization laboratory team begins the procedure and calls you to discuss the case. They note a sinus rhythm at 90 bpm with occasional premature ventricular contraction and a central venous pressure of 4 mmHg and nonelevated end-diastolic pressures at the beginning of the study (due to recent diuresis); they are unable to elucidate diastolic equalization of pressures, significant “dip and plateau,” or respiratory discordance of the ventricular pressure waveforms.

A potential mechanism for the discordant catheterization findings would be

a.lack of preload due to overdiuresis.

b.borderline tachycardia and ectopy preventing accurate analysis.

c.presence of only mild constrictive physiology.

d.presence of restrictive cardiomyopathy and physiology.

8.A 32-year-old white man presented initially with low-grade fever, cough, and pleuritic chest pain. He was found on ECG to have diffuse ST-segment elevation. A transthoracic echocardiogram (TTE) revealed a large pericardial effusion, and serologies were positive for coxsackievirus B infection. He was diagnosed with acute viral pericarditis and treated with indomethacin. He returns 4 weeks later for follow-up and states that he no longer has any pain, but he notes some mild ankle swelling. His ECG is normal. A repeat TTE shows resolution of the effusion but new findings consistent with mild constriction. What is the next step in managing this patient?

a.Obtain cardiac MRI to better assess the pericardium.

b.Have a cardiothoracic surgical consultation for pericardiectomy.

c.Reassure the patient and observe him over the next 3 months for worsening of symptoms.

d.Start a course of steroids.

9.A 45-year-old woman with a history of treated carcinoma of the breast presents to the local emergency department with a few days of severe chest pain. In the emergency department, she appears ill and pale and in moderate discomfort. Her BP is 135/60 mmHg; her respiratory rate is 24 breaths per minute; her HR is 82 bpm; and her temperature is 100.8°F. The resident on call reads her chest X-ray (CXR) as unremarkable. Her ECG is shown in Figure 13.1. What is the most reasonable next step?

a.Give aspirin and nitroglycerin and prepare to administer thrombolytics.

b.Call the cardiac intervention team and rush the patient to the catheterization laboratory for emergency coronary intervention.

c.Give a nonsteroidal anti-inflammatory medication.

d.Discharge the patient and refer her for a gastroenterology follow-up as an outpatient.

10.A 59-year-old man with a history of coronary artery disease (CAD) and remote coronary bypass surgery presents with progressive dyspnea and vague chest pain. He had a stress echocardiogram for these symptoms that demonstrated normal LV function with no stress-induced wall motion abnormalities. However, he returned to the emergency department a few days later with recurrent symptoms. This time the house officer examining the patient notes 3+ pedal edema. The patient is admitted and started on diuretics. His blood tests are as follows:

White blood cell count = 11,000

Hemoglobin = 14.2

Platelets = 172,000

Albumin = 4.6

Urea = 11

Creatinine = 0.9

Figure 13.1 • (From Wagner GS, ed. Marriott’s Practical Electrocardiography, 9th ed. Baltimore, MD: Williams & Wilkins; 1994, with permission.)

Owing to the recurrent symptoms, his cardiologist decides to refer him for a right and left heart catheterization. The coronary grafts are all patent. The tracings from the study are shown in Figure 13.2. What is the most logical explanation for this patient’s symptoms?

a.Constrictive pericardial disease

b.Small-vessel CAD

c.Diastolic dysfunction related to his chronic CAD

d.Cardiac amyloid

e.Cardiac tamponade

Figure 13.2 • PCW, pulmonary capillary wedge.

11.A 73-year-old man with no cardiac history presents with chronic lower extremities edema. His primary care physician attributed his symptoms to old age. He was treated with hydrochlorothiazide. Initially, he reported a good response to the therapy, but, over the past few months, his edema recurred, and doubling the diuretic dose did not alleviate his symptoms. On his initial examination, you notice distended neck veins and a quiet precordium. He has mild hepatomegaly and 4+ pedal edema. A TTE is suboptimal because of the patient’s inability to lie flat and obstructive lung disease. His blood work is as follows:

White blood cell count = 6,000

Hemoglobin = 12.7

Platelets = 225,000

Urea = 43

Creatinine = 2.4

Albumin = 3.6

A cardiac catheterization is performed. He has normal coronary arteries with mild impairment in LV systolic function. The tracings from the study are shown in Figure 13.3. What is your explanation of his symptoms?

a.You agree with his primary care physician. You tell the patient that he probably has peripheral venous insufficiency.

b.This patient has significant diastolic dysfunction, and his prognosis is guarded.

c.This patient’s symptoms are due to the LV systolic dysfunction and volume overload.

d.This patient should be referred for surgical evaluation for possible pericardial stripping.

Figure 13.3 • Pressure tracings in the LV and RV.

12.A 56-year-old male smoker with a family history significant for CAD is presenting with dyspnea on exertion and nonexertional vague chest pain. His physical examination and his initial ECG are unremarkable. His CXR demonstrates an increased cardiac silhouette. There is also a small nodule seen in his right upper lobe. The radiologist is not certain about its significance. Given his risk factors and symptoms, he is referred for a perfusion stress test. The images from the stress test are shown in Figure 13.4. Which of the following does the patient clearly have?

a.He has coronary ischemia and should be referred for coronary angiography.

b.There is no evidence of pathology to justify his symptoms.

c.His symptoms are related to impairment of RV filling and pericardial disease.

d.He has mild ischemia and can be treated medically.

Figure 13.4 • (From Pohost GM, O’Rourke GA, Berman DS, et al., eds. Imaging in Cardiovascular Disease. Philadelphia, PA: Lippincott Williams & Wilkins; 2000, with permission.)

13.A 58-year-old man, with cardiac risk factors of tobacco use, hypertension, and hypercholesterolemia, presented to the emergency department a few days ago with an acute onset of left-sided chest pain. His evaluation revealed a diaphoretic man in moderate discomfort. An ECG was performed and showed a pattern consistent with an inferior wall acute MI. The patient was treated with thrombolytics. Forty-five minutes after the initial dose of the thrombolytics, he felt better and had complete resolution of his symptoms and normalization of the ECG. On the third day after the event, he reports midsternal chest pain, vague in nature, with mild diaphoresis and shortness of breath. An ECG is performed, as shown in Figure 13.5. Which of the following should you tell the patient is the next step in managing his condition?

a.There is evidence of reocclusion of the infarct-related artery, and a percutaneous intervention is needed.

b.There is evidence of reocclusion of the infarct-related artery, and rebolus with thrombolytics and heparin is indicated.

c.He is showing signs of early postinfarction pericarditis, and a nonsteroidal anti-inflammatory medication should be started.

d.An LV aneurysm has developed, and a TTE is needed to evaluate the extent of the aneurysm.

Figure 13.5 • (From Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine, 5th ed. Philadelphia, PA: WB Saunders; 1997, with permission.)

14.A 19-year-old male college student presents to his local physician for evaluation of a dry cough. His symptoms started 3 days ago but now appear to be resolving. He had planned a trip overseas but was concerned and is now seeking advice. His physical examination is unremarkable. A CXR is performed and is read as showing an enlarged right cardiac silhouette. A TTE is ordered, which is shown in Figure 13.6. The patient most likely has which of the following conditions?

a.He has a pericardial cyst that is benign; no further treatment should be offered.

b.He has cardiac tamponade requiring a pericardial tap.

c.He has a pleural effusion.

d.There is no pathology. The CXR was misread.

e.He has mesothelioma.

Figure 13.6

15.You are called to the emergency department to see a 74-year-old man. He has a history of heavy smoking and hypertension. The patient cannot remember his medications, but he reports not taking them on a routine basis. In the past few hours before presentation, he experienced a sudden onset of severe left-sided chest pain with radiation to the left scapula. Approximately half an hour later, he noted some difficulty breathing. In the emergency department, he is noted to be diaphoretic and in significant respiratory distress. His physical examination reveals a BP of 160/90 mmHg, elevated jugular venous pressures, and a quiet precordium. His ECG is reported as sinus tachycardia with no acute ST-T changes. After initial pain and BP management, a transesophageal echocardiography (TEE) is performed to rule out aortic dissection. The findings of the TTE are shown in Figure 13.7. What is your recommendation?

a.The patient should have immediate surgical intervention.

b.The patient needs BP control and surgical evaluation once he is medically stabilized.

c.The patient should have percutaneous pericardial drainage to manage the cardiac tamponade and then a surgical evaluation.

d.The diagnosis is unclear; a computed tomographic (CT) scan or an aortic angiogram is needed.

Figure 13.7

16.A 42-year-old man was referred for evaluation of symptomatic mitral regurgitation. He was diagnosed with mitral valve prolapse that was not suitable for repair. Given his family history of CAD and tobacco use, he underwent a coronary angiogram, which revealed no evidence of obstructive coronary disease. He underwent an uneventful mitral valve replacement. He was extubated and transferred from the intensive care unit 48 hours after the operation. On postoperation day 3, you note the patient to be pale and lethargic and in mild respiratory distress. His BP is 100/60 mmHg. His cardiac and lung examination is compromised by the presence of rapid breathing and chest tubes. His ECG reveals normal sinus rhythm (NSR) at 97 bpm with no acute ST-T changes. A TTE is performed. Selected views are shown in Figure 13.8A. As the patient continues to deteriorate and becomes hypotensive, a TEE is performed next, as shown in Figure 13.8B. What should you recommend?

a.Immediate surgical exploration of the pericardium

b.Percutaneous aspiration of the fluid present in the pericardium

c.Immediate surgical intervention for malfunction of the prosthetic mitral valve

d.A 500-cc bolus of IV normal saline solution should be started because the patient is dehydrated, and no further intervention is needed

Figure 13.8

17.A 49-year-old black man with hypertension and chronic renal insufficiency presents with dyspnea and fluid overload with decreased urine output. He is treated in the hospital with diuretics, and his symptoms improve. However, his renal function continues to deteriorate with an increasing blood urea nitrogen of 90 and a creatinine of 5.4. In addition, the patient is noted to have several bruises on his arms from needlestick blood draws and IV lines. On hospital day 4, the patient is noted to be hypotensive and tachycardic: BP, 80/40 mm Hg; HR, 110 bpm. No jugular venous distention is noted, but heart sounds are diminished, and a loud pericardial rub is heard. His TTE is shown in Figure 13.9. What is the next step in management?

a.Urgent pericardiocentesis

b.IV hydration

c.Immediate dialysis

d.The continuation of diuretics with serial TTE

Figure 13.9 • (From Otto CM, Pearlman AS. Textbook of Clinical Echocardiography. Philadelphia, PA: WB Saunders; 1995, with permission.)

18.A 42-year-old white male chef is brought into the emergency department after a motor vehicle accident in which he fell asleep at the wheel and ran into a tree. He is reporting anterior chest discomfort and shortness of breath. He relates no prior medical conditions and takes no medications. Vitals are stable with a BP of 120/60 mmHg and an HR of 90 bpm. His ECG is shown in Figure 13.10A. A TTE is performed. Diastolic images are shown in Figure 13.10B. Laboratory tests show modest elevation of creatinine phosphokinase at 240. Which of the following is the most reasonable next step in managing this patient?

a.Start the patient on a nonsteroidal anti-inflammatory agent with follow-up as an outpatient in 1 week.

b.Admit the patient for observation on telemetry with a follow-up TTE.

c.The patient needs immediate percutaneous revascularization.

d.Send the patient for surgical treatment of pericardial rupture.

Figure 13.10A • (From Chou T-C. Electrocardiography in Clinical Practice, 4th ed. Philadelphia, PA: WB Saunders; 1996, with permission.)

Figure 13.10B • (From Chou T-C. Electrocardiography in Clinical Practice, 4th ed. Philadelphia, PA: WB Saunders; 1996, with permission.)

19.A 22-year-old white man is newly diagnosed with non-Hodgkin lymphoma. He undergoes a metastatic workup that includes an MRI of the chest and abdomen, which is shown in Figure 13.11. The plan is for chemotherapy, but you are consulted for cardiac assessment before beginning chemotherapy. Radionuclide ventriculography shows a normal LV EF of 65%. What should you recommend?

a.Ordering a TTE to delineate the abnormality

b.Cardiothoracic surgical consultation before starting chemotherapy

c.Exercise stress testing

d.Proceeding with chemotherapy without further cardiac evaluation

Figure 13.11 • (MRI image was provided by Dr. Richard White, Head, Section of Cardiovascular Imaging, Departments of Radiology and Cardiovascular Medicine, The Cleveland Clinic Foundation.)

20.A 44-year-old white man with rheumatoid arthritis is referred to your office for evaluation after his rheumatologist heard a loud heart sound. On questioning, the patient mainly reports joint pains in his fingers. He denies any chest discomfort or shortness of breath. He has been on methotrexate and prednisone for the past year. His examination is significant for mild erythema and swelling of his distal interphalangeal joints, rheumatoid nodules on his right forearm, clear lungs, distant heart sounds with a loud friction rub, and moderate peripheral edema. You order a TTE to further assess his heart. Selective images are shown in Figure 13.12. What is your recommendation?

a.Because he currently has no cardiac symptoms, no further treatment is needed except to continue methotrexate and prednisone.

b.You want the patient to start indomethacin, continue methotrexate and prednisone, and follow up in 4 weeks.

c.The best treatment at this time for his pericardial effusion is drainage with the instillation of steroids to prevent recurrence.

d.A surgical evaluation for pericardiectomy is necessary because the findings on his TTE indicate that he will develop problems in the future if this is not taken care of soon.

21.A 55-year-old white man presents for evaluation of chest pain. He has no prior medical problems, but he has noted burning epigastric and chest discomfort for the past few months for which he was taking antacids with some relief of his symptoms. However, because the symptoms persisted, he sought medical attention and was referred for an esophagogastroduodenoscopy, which was performed earlier today. He was found to have a fundal hiatal hernia with a gastric ulcer that was cauterized, and he was started on omeprazole. On returning home, he noted a new sharp anterior chest pain, somewhat positional related, that was not relieved with antacids or omeprazole. This pain progressively worsened over the next few hours, and he came to the emergency department. Examination in the emergency department revealed a temperature of 38.1°C, an HR of 110 bpm, and a BP of 120/70 mmHg. Lung sounds were clear. Heart sounds appeared normal with the patient sitting upright, but they were diminished with the patient lying in the supine position. An ECG did not show any acute ST-T wave abnormalities to suggest infarction. A CXR was performed, as shown in Figure 13.13. You are called to further assess the patient. After reviewing the available data, which of the following is your next step?

a.Immediate surgical consultation

b.Immediate pericardiocentesis

c.Start a nonsteroidal anti-inflammatory medication and admit him for observation

d.No further treatment is needed because his symptoms are caused by the hiatal hernia

Figure 13.12

Figure 13.13 • (From Spodick DS. The Pericardium: A Comprehensive Textbook. New York: Marcel Dekker; 1997, with permission.)

22.A 71-year-old man presents to the hospital with palpitations of 2 to 3 days’ duration. He has no known medical history, and he is not on any medications. Initial evaluation is unremarkable except for a BP of 160/90 mmHg and an ECG showing atrial fibrillation with a ventricular rate of 120 to 130 bpm. Given the duration of his symptoms, he is treated with β-blockers for rate control and heparin for anticoagulation. On hospital day 2, he is referred for early transesophageal-guided cardioversion. The TEE reveals normal LV and RV function. There are no echocardiographic contraindications for cardioversion. An uneventful cardioversion is performed, and the patient converts to NSR. On hospital day 3, the patient is found in marked respiratory distress. On physical examination, he has a regular HR with a loud audible click over the precordium. A CXR is performed, as shown in Figure 13.14. What does this patient have?

a.He has a pulmonary embolism and should be treated with thrombolytics.

b.He has a hiatal/diaphragmatic hernia with compression of the heart by the fundus of stomach.

c.He has an iatrogenic pneumohydropericardium; immediate drainage and surgical attention are needed.

d.He has a recurrence of atrial fibrillation.

Figure 13.14 • (From Spodick DS. The Pericardium: A Comprehensive Textbook. New York: Marcel Dekker; 1997, with permission.)

23.A 59-year-old woman with a history of chronic renal insufficiency presents to the emergency department with anterior left-sided chest pain. She reports that the chest pain started after her last dialysis 7 days ago. She appears lethargic and in mild respiratory distress. The physical examination demonstrates a BP of 160/90 mmHg and an HR of 100 bpm. On cardiac auscultation, a loud friction rub is heard. An ECG is obtained (Fig. 13.15). What is the most important next step in this case?

a.Perform emergency dialysis.

b.Obtain an echocardiogram.

c.Prepare for pericardiocentesis.

d.Admit the patient to the cardiac care unit to rule out MI.

Figure 13.15 • (From Spodick DS. The Pericardium: A Comprehensive Textbook. New York: Marcel Dekker; 1997, with permission.)

24.A 29-year-old woman with known insulin-dependent diabetes mellitus was found unconscious 1 hour after an office party. Initial assessment by the emergency medical service team showed a BP of 90/60 mm Hg. Her pulse was 120, and her blood sugar was 870 mg/dL. She was given SC insulin and rushed to the emergency department. You are called to see her because of her abnormal ECG (Fig. 13.16). She is noted to be semiconscious. The emergency physician has already started her on IV insulin drip and hydration. What is your recommendation at this juncture?

a.She is having an acute MI, and immediate restoration of coronary flow is essential.

b.She has ECG evidence of hyperkalemia, and she needs IV calcium and, possibly, dialysis.

c.Continue the current management; the ECG will improve with the resolution of ketoacidosis.

d.Her ECG predicts high-degree atrioventricular block; a standby external pacemaker should be available.

Figure 13.16 • (From Spodick DS. The Pericardium: A Comprehensive Textbook. New York: Marcel Dekker; 1997, with permission.)

25.Which of the following is the most common neoplastic pericardial tumor in adults?

a.Neuroma

b.Hemangioma

c.Mesothelioma

d.Teratoma

ANSWERS

1.a. Presence of an ASD. The presence of the iatrogenic ASD after the transseptal puncture for the radiofrequency ablation/pulmonary vein isolation procedure equates right atrial (RA) and left atrial (LA) pressures with inspiration. The predicted decrease in LV filling during inspiration due to interventricular dependence and exaggerated RV filling and septal shift toward the LV is mitigated by the presence of an ASD. With inspiration, the decrease in intrathoracic pressure is transmitted to both atria and thus preload to the LV is maintained and interventricular dependence is not as pronounced. Thus, the variation in systolic blood pressure is not as prominent, resulting in minimal to no pulsus paradoxus. Administration of excess fluid would stave off circulatory collapse in tamponade; however, it would not diminish the pulsus. Answer b is incorrect as with severe LV dysfunction, patients can have a pulsus alternans (variation in peak systolic pressure with every other beat) and Answer c is incorrect as obstructive lung disease can lead to the presence of a pulsus due to exaggerated inspiratory effort and negative intrathoracic pressure.

2.a. Ibuprofen 600 TID for 2 weeks followed by taper and colchicine 0.5 mg BID for 3 months. The patient presents with an initial attack of acute pericarditis without any high-risk features (small effusion, negative troponin, no fever/trauma, or anticoagulant use). The appropriate regimen in this case would be an NSAID (ibuprofen 600 to 800 mg TID or indomethacin 50 mg TID) for a course of 1 to 2 weeks with physician follow-up. In addition, the use of colchicine has been studied in two trials with improvement in symptom resolution and maintenance of remission at a dose of 0.5 mg (daily for <70 kg; BID for >70 kg) for a fixed period of 3 months.

Aspirin and colchicine can be used together; however, the dosing is incorrect for Answer b (650 to 1,000 mg TID) and the colchicine should still be continued for 3 months. Prophylactic Proton-pump inhibitor (PPI) should be utilized during the high-dose NSAID use to prevent gastric ulcer. Answer c is incorrect (dosing of ibuprofen is incorrect). Answer d is incorrect since steroid therapy is only reserved for patients with NSAID or acetylsalicylic acid (ASA) contraindication or patients having relapsing pericarditis that is refractory to NSAID/ASA therapy.

3.a. Aspirin 650 TID for 2 weeks with taper to 81 mg daily + colchicine 0.5 mg BID for 3 months. The patient has postinfarction pericarditis with a typical presentation after reperfusion for late-presenting MI. Although not as frequent, postinfarction pericarditis (Dressler syndrome) is still seen in a small percentage of patients after large MI, and cardiac/pericardial trauma. The regimen used in these patients is modified to include aspirin (instead of NSAIDs) for two reasons: (a) aspirin is required for patients with CAD, with or without recent stenting; and (b) NSAIDs are postulated to impair scar formation and wound healing after an MI. Colchicine is still part of the regimen despite the recent MI and helps with symptom resolution. Correct answer is a—with high-dose aspirin initially with gradual taper once symptoms improve. The clopidogrel is continued despite high doses of aspirin, due to the placement of a recent intracoronary stent.

4.a. Initiate steroid therapy (0.25 to 0.5 mg/kg/day) along with colchicine, and initiate PO diuretic. The patient had acute pericarditis, which transformed into a chronic effusive constrictive pericarditis. There is evidence of therapy failure (persistent symptoms and elevated biomarkers) and ongoing inflammation, leading to symptomatic constrictive pericarditis with increasing hemodynamic significance (as demonstrated by symptoms/physical examination and echo findings). The next step would be to escalate anti-inflammatory therapy to include glucocorticoids (prednisone) to help abate the ongoing symptoms and pericardial inflammation. Glucocorticoids are generally not first-line therapy since patients who receive them early in the course of the disease process are more likely to have relapsing pericarditis and eventually develop constrictive pericarditis. In the case of this patient, he does not have any other treatment options due to his NSAID allergy, so steroids should be initiated at a low dose and maintained with very gradual taper (weeks to months) that involves assessment of his symptoms, biomarker trend (ESR/hsCRP), as well as MRI findings to assess for inflammation/edema within the pericardium to help quell the disease process.

Admission for IV diuresis is not necessary as the patient has not proven resistance to PO diuretics and although a cardiac catheterization may be required alternative noninvasive diagnostic modalities should be performed prior to catheterization to make the diagnosis. Answer c is incorrect since the patient has demonstrated treatment failure with progression of symptoms in the interim. Answer d is incorrect as medical therapy options (steroids, diuresis) are still available. Pericardiectomy is generally reserved in medically refractory cases.

5.a. Tuberculous pericarditis. The patient presents with acute tuberculous pericarditis with large exudative effusion. Indolence of the effusion is likely over months; however, the salient findings in the fluid analysis are the elevated interferon gamma, ADA, and normal peripheral white blood cell count with pericardial lymphocyte predominance. The presence of interferon gamma elevation had a 92% sensitivity, 100% specificity, and 100% positive predictive value for tuberculous pericarditis. ADA was also linked to tuberculous pericarditis; however, it was not as sensitive or specific (87%/92%).

Although Answers b and c are epidemiologically possible, the fluid analysis is not suggestive of either. Pericardial biopsy (Answer d) is incorrect as tuberculous pericarditis can be defined by the interferon gamma and ADA elevation. Also Acid-Fast Bacilli (AFB) staining will reveal AFB + organisms confirming diagnosis. Biopsy should be reserved for patients with unrevealing fluid analysis who are still symptomatic and require further diagnostic testing to make a diagnosis.

6.a. Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities (E’ septal > E’ lateral) and annulus paradoxus refers to inverse correlation of E/E’ and LV end-diastolic pressure. The annulus reversus phenomenon describes a reversal of mitral lateral and septal tissue Doppler velocity. Normally, E’ lateral > E’ septal; however, in constrictive pericarditis it is postulated that tethering of the free wall prevents longitudinal motion of the annulus at the lateral border, thus decreasing the lateral E’ and the septal E’ concurrently is mildly exaggerated.

The annulus paradoxus phenomenon was initially described after data looking at the correlation between the E/E’ ratio and pulmonary capillary wedge pressure were established. In a small subset of patients with constrictive pericarditis, inversion of the correlation between E/E’ and PCWP was noted, and named annulus paradoxus.

7.a. Lack of preload due to overdiuresis. Volume loading is required to elucidate the diagnostic findings described above. Constrictive pericarditis is a preload-dependent condition and with overdiuresis and low central venous pressure, the hemodynamic findings of elevated and equal end-diastolic ventricular pressure waveforms as well as respiratory discordance of the LV/RV waveforms are not seen. Often in these cases, the patient is given a bolus of 1 to 2 L of normal saline to increase the RA pressure >12 to 15 mmHg and the study is performed once they are adequately volume loaded. Of note, in cases of atrial fibrillation, the patient may require a temporary venous pacemaker to regularize the rhythm for analysis purposes.

8.c. Reassure the patient and observe him over the next 3 months for worsening of symptoms. The natural history of acute viral or idiopathic pericarditis is usually short and self-limited. Occasionally, mild forms of constriction may develop weeks after the initial event, but they usually resolve without any specific treatment. No further treatment is indicated unless he becomes more symptomatic or develops signs of cardiac tamponade.

9.c. Give a nonsteroidal anti-inflammatory medication. The clinical presentation of a few days of severe chest pain does not favor an acute MI. Furthermore, the ECG tracing supports the diagnosis of pericarditis. Therefore, cardiac catheterization and thrombolytics are not appropriate. The only reasonable answer is to start the patient on anti-inflammatory medications and obtain a TTE to rule out pericardial effusion.

10.a. Constrictive pericardial disease. This patient did not have evidence of ischemia on a recent stress test. Furthermore, there is no evidence of obstructive disease in his coronaries or grafts. His tracings mostly support the diagnosis of constriction, given the diastolic equalization of pressures in the cardiac chambers and the typical square root sign. Amyloidosis would typically show signs of restrictive hemodynamics with no respiratory variation. Echocardiography typically shows increased LV wall thickness. Additionally, a diagnosis of tamponade should have been evident by echocardiography, which the patient had before heart catheterization. Otherwise, hemodynamic tracings of cardiac tamponade would look exactly the same as for constriction.

11.b. This patient has significant diastolic dysfunction, and his prognosis is guarded. He has evidence of restrictive LV filling (advanced diastolic dysfunction) in the absence of CAD. The differential diagnosis in his age group includes amyloidosis (especially considering concomitant renal dysfunction), hemochromatosis, and other infiltrative processes.

12.c. His symptoms are related to impairment of RV filling and pericardial disease. This patient with the main presentation of dyspnea has an increased cardiac silhouette. The nuclear image provided shows a circumferential echolucency surrounding the heart. This is consistent with a large pericardial effusion, and he most likely has RA and RV diastolic compromise. There is no evidence of a perfusion defect to suggest ischemia.

13.c. He is showing signs of early postinfarction pericarditis, and a nonsteroidal anti-inflammatory medication should be started. This patient had an MI 72 hours ago that was successfully treated with thrombolytics. The ECG shows diffuse ST elevation with PR depression. These findings support the diagnosis of post-MI pericarditis. The ECG changes are new and nonlocalizing. Most patients improve with nonsteroidal anti-inflammatory medications.

14.a. He has a pericardial cyst that is benign; no further treatment should be offered. The TTE and CXR show a pericardial cyst. Pericardial cysts are usually smooth structures containing transudative fluid. They are frequently only 2 or 3 cm in diameter, often located at the right cardiodiaphragmatic angle, and clinically silent. However, cysts can be associated with chest pain, dyspnea, cough, and arrhythmias likely caused by compression of adjacent tissues. They can also become secondarily infected. In this patient, whose nonspecific symptoms appear to be resolving, no further treatment is needed.

15.a. The patient should have immediate surgical intervention. This patient has evidence of acute type A aortic dissection with extension to the pericardium, as evidenced by the pericardial effusion on the TEE. He should be immediately referred for surgical repair. If the diagnosis were not certain based on the TEE, then CT, MRI, or aortic angiography would be needed to better define the anatomy. The safest and most efficient management of patients with aortic dissection is to carry out all diagnostic procedures in the operating room. Pericardial drainage often gives only temporary relief or no relief of the tamponade, and the subsequent increase in BP disrupts sealing clots, accelerating intrapericardial leakage.

16.a. Immediate surgical exploration of the pericardium. The TTE and TEE demonstrate a pericardial hematoma compromising RA and RV filling. This is an indication for surgical exploration and evacuation of the hematoma.

17.b. IV hydration. This patient has evidence of pericarditis likely related to uremia, as he is close to requiring dialysis. Although his TTE shows signs of tamponade (RA collapse, moderate-sized effusion, and respiratory variation across the mitral inflow), there is no jugular venous distention, and the inferior vena cava is small sized, indicating that this patient has been overdiuresed. His hypotension and tachycardia are related to dehydration. He should, therefore, be treated with IV hydration.

18.b. Admit the patient for observation on telemetry with a follow-up TTE. The ECG shows findings consistent with an anterior wall injury, and the TTE shows a small pericardial effusion. Given this patient’s history, he most likely has a cardiac contusion. Although the prognosis for recovery is generally excellent, these patients require careful monitoring and follow-up for late complications, which range from ventricular arrhythmias to cardiac rupture. Hence, the most logical answer to this question is to admit the patient to a telemetry bed with follow-up TTE.

19.d. Proceeding with chemotherapy without further cardiac evaluation. This patient’s MRI shows congenital absence of the pericardium. This is a benign condition usually found incidentally. No specific cardiac treatment is needed unless there is entrapment of one of the cardiac chambers.

20.d. A surgical evaluation for pericardiectomy is necessary because the findings on his TTE indicate that he will develop problems in the future if this is not taken care of soon. The patient is currently symptomatic with edema of the lower extremities. Furthermore, he has a pericardial friction rub suggestive of an active pericardial process likely related to his rheumatologic disease process. He is already on methotrexate and prednisone as anti-inflammatory medications. Pericardial effusions related to rheumatoid arthritis often progress to constriction despite anti-inflammatory therapy, and early management consisting of pericardial stripping is recommended.

21.b. Immediate pericardiocentesis. The next step is an immediate pericardiocentesis. This patient has signs of early sepsis. Furthermore, the CXR shows pneumopericardium that likely developed secondary to gastric perforation from the esophagogastroduodenoscopy and cauterization of the ulcer. This patient needs immediate referral to surgery for repair.

22.c. He has an iatrogenic pneumohydropericardium; immediate drainage and surgical attention are needed. This patient had a TEE that most likely resulted in an esophageal tear with communication to the pericardial sac. On the CXR, there is a lucent triangle outlining the pericardium with pericardial passage over the aortic arch.

23.a. Perform emergency dialysis. This patient has missed her dialysis session and is now presenting with hyperkalemia (note peaked T waves on ECG) and uremic pericarditis. The most essential step is to start dialysis to treat the hyperkalemia.

24.c. Continue the current management; the ECG will improve with the resolution of ketoacidosis. Patients presenting with diabetic ketoacidosis can have ECG features that are typical of stage I pericarditis and hypokalemia. The treatment is usually that of ketoacidosis. The ECG returns to normal after resolution of the acidosis.

25.c. Mesothelioma. Teratoma is the most common pericardial tumor in infancy and childhood. Neuroma and hemangioma are uncommon enough to be considered curiosities.

SUGGESTED READINGS

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Ha JW, Oh JK, Ling LH, Nishimura RA, Seward JB, Tajik AJ. Annulus paradoxus: transmitral flow velocity to mitral annular velocity ratio is inversely proportional to pulmonary capillary wedge pressure in patients with constrictive pericarditis. Circulation. 2001;105:976–978.

Hoit BD. Management of effusive and constrictive pericardial heart disease. Circulation. 2002;105(25):2939–2942.

Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369:1522–1528.

Klein AL, Asher CR. Diseases of the pericardium, restrictive cardiomyopathy, and diastolic dysfunction. In: Topol EJ, ed. Textbook of Cardiovascular Medicine, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002.

Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med. 2004;351:2195.

Reuss CS, Wilansky SM, Lester SJ, et al. Using mitral “annulus reversus” to diagnose constrictive pericarditis. Eur J Echocardiogr. 2009;10:372–375.

Reuter H, Burgess L, van Vuuren W, Doubell A. Diagnosing tuberculous pericarditis. QJM. 2006;99:827–839.

Spodick DS. The Pericardium: A Comprehensive Textbook. New York: Marcel Dekker; 1997.