Test: Pericardial Diseases - NEET PG MCQ

• The findings of hypotension with elevated JVP and reduced breath sounds points to diagnosis of Tension pneumothorax.
• In cardiac tamponade same finding would be seen but breath sounds would not be affected.
• A large bore needle should be inserted into the pleural space through second intercostal space to allow escape of air and improvement in hemodynamic status of the patient. The needle should be left in place until a thoracostomy tube can be placed.

For demonstration of pulsus paradoxsus which is a feature of cardiac tamponade, the patient has to breath normally.
Procedure for measurement of Pulsus paradoxsus

• The patient Is placed in a semi-recumbent position
• Respirations should be normal
• The blood pressure cuff is Inflated to at least 20 mm Hg above the systolic pressure and slowly deflated until the first Korotkoff sounds are heard only during expiration.
• At this pressure reading, if the cuff Is not further deflated and if pulsus paradoxus is present, the first Korotkoff sound is not audible during inspiration.
• As the cuff Is further deflated, the point at which the first Korotkoff sound is audible during both inspiration and expiration is recorded.
• If the difference between the first and second measurement is greater than 12 mm Hg, an abnormal pulsus paradoxus is present.
• The paradox is that while listening to the heart sounds during Inspiration, the pulse weakens or may not be palpated with certain heartbeats.

• BP cuff is inflated 20 mm Hg above systemic pressure in case of eliciting trousseau sign and not pulsus paradoxus. Hence choice A is wrong. Pulsus paradoxus is a >10 mm Hg fall in systolic pressure with inspiration and is considered pathological and a sign of pulmonary or pericardial disease.
• Cardiac tamponade is characterised by intra-pericardial pressure exceeding LVEDP leading to diastolic collapse of ventricles. This results in crashing of BP and appearance of pulsus paradoxus.
• In contrast the low pressure cardiac tamponade is characterized by intra-pericardial pressure exceeding only the intra-atrial pressure leading to under filling of ventricles and results in only hypotension. Since it is a milder condition pulsus paradoxus will be absent. Hence choice B is correct.
• If patient is asked to lake deep breaths in will result in possible syncope as pulse is disappearing on inspiration. Hence choice C is wrong.
• Pulsus paradoxus is measured by noting the difference between the systolic pressure at which the Korotkoff sounds are first heard (during expiration), and the systolic pressure at which the Korotkoff sounds are heard with each beat, independent of respiratory phase. Hence choice D is wrong as it says only expiration.
• Causes of Pulsus paradoxus
  1. Pericardial tamponade
  2. Massive pulmonary embolus
  3. Hemorrhagic shock
  4. Severe obstructive lung disease
  5. Tension pneumothorax
  6. Obesity and pregnancy

The presence of low grade fever and dyspnea indicates an infective pathology. The CXR shows an increased CT Ratio which could be a tuberculous pericardial effusion. The diagnosis is given more credence due to ECG showing Low voltage ECG which is seen with an effusion.
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• The three principal features of tamponade (Beck's triad) are hypotension, soft or absent heart sounds, and jugular venous distention with a prominent x descent but an absent y descent.
• There are both limitation of ventricular filling and reduction of cardiac output. The quantity of fluid necessary to produce this critical state may be as small as 200 mL when the fluid develops rapidly or > 2000 mL in slowly developing effusions when the pericardium has had the opportunity to stretch and adapt to an increasing volume.
• Tamponade may also develop more slowly, and in these circumstances the clinical manifestations may resemble those of heart failure, including dyspnea, orthopnea, and hepatic engorgement.
• There may be reduction in amplitude of the QRS complexes, and electrical alternans of the P, QRS, or T waves should raise the suspicion of cardiac tamponade.

Beck’s triad is a collection of three medical signs associated with acute cardiac tamponade, an emergency condition wherein fluid accumulates around the heart and impairs its ability to pump blood. The signs are:

• Low arterial blood pressure
• Distended neck veins
• Distant, muffled heart sounds.

Constrictive pericarditis can present with hypotension and congested neck veins but muffled heart sounds are not present.

Dressier syndrome is post MI pericarditis/Pleuritis and is characterized by autoimmunity causing damage to the heart. The resultant inflammation causes chest pain in these patients uptn 6 weeks of a preceding myocardial inflammation. The investigations show ECG evidence of pericarditis with ST elevation with concavity in upwards direction. The CPKMM levels are normal. The treatment of these patients shall be aspirin 650 mg TID.

• Since in the CXR, the cardiac borders look bulging and CT ratio is increased, the finding is that of a water bottle heart/ money bag appearance. In clinical setting of hypotension with distended neck veins, this patient is having a massive pericardial effusion and developing findings of a tamponade.
• The point against cor pulmonale is that it is characterized by right ventricular failure with pulmonary artery hypertension. But in this CXR, pulmonary artery segment is not bulging.

• Constrictive pericarditis and restrictive cardiomyopathy are clinical entities, which possess similar diagnostic signatures.
• However, constrictive pericarditis requires surgical treatment and is usually curable, while restrictive cardiomyopathy, needs cardiac transplantation.
• Therefore, the differentiation of constriction and restriction is important.
• Mixed physiology of constriction and restriction has been also reported in cases with prior radiation exposure to the chest.
• Progressive fibrosis can cause restrictive myocardial disease without dilation. Thoracic radiation, common for breast and lung cancer or mediastinal lymphoma, can produce early or late restrictive cardiomyopathy. Patients with radiation cardiomyopathy may present with a possible diagnosis of constrictive pericarditis, as the two conditions often coexist.