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 Pulsus severity Sensitivity % Specificity % Positive LR Negative LR >10mmHg52-6869-922.70.5 >20mmHg19-3992-1008.20.8 >25mmHg169922.60.8 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. Malignant Thymoma, RV failure, Pericardial Tamponade CXR