82-year-old male, with a history of HTN, HLD, and CAD, presents to your clinic with a six-month history of dyspnea on exertion.  He states he is unable to walk as far as he used when exercising, and when he over exerts himself, he reports having some mild chest pain and feeling lightheaded.  This resolves with rest and he denies any syncope with these events.

Medications

Metoprolol 50mg daily

Lisinopril 10mg daily

Simvastatin 30mg daily

Vital Signs

BP – 158/97

HR – 62

RR – 13

O2% – 100%

Physical exam

General – WN/WD male in NAD

Pulmonary – CTA without adventitial breath sounds

CV – Soft S2 with murmur over right 2nd intercostal space

PV – carotid pulse is weak and has a slow rise, murmur is appreciated

Neuro – No focal deficits

EKG

This patient has aortic stenosis.  The suggestive parts of the H&P are:

• History
  • The classic triad of aortic stenosis is chest pain, dyspnea, and syncope.
• Aortic stenosis increases in prevalence with age
• Cardiac Auscultation
  • Soft, single S2 since A2, which is due to aortic valve closure, is delayed and occurs with P2
  • Murmur
    • Systolic ejection murmur best heard over the right 2nd intercostal space
    • 
    • Begins on S1 and ends before S2
    • May radiate to the carotids
    • 
• Peripheral Vascular
  • Carotid Palpation
  • Pulsus Parvus et Tardus (weak and late)
  • 
• EKG
  • Shows LVH and strain pattern in precordial leads

1. What is the next step in the management of this patient?
   1. Transthoracic echocardiography
2. After the next step, what important variables must you specifically assess?
   1. Valvular anatomy and size
      1. Aortic valve surface area
   2. Valve hemodynamics
      1. Transvavular aortic velocity
      2. Mean transvalvular pressure
   3. LV size and ejection fraction
   4. Pulmonary artery pressure
   5. Other concomitant conditions

These variables will help with staging the severity of the stenosis, as well as determine need for operative intervention.

82-year-old male, with a history of HTN, HLD, and CAD, presents to your clinic with a six-month history of dyspnea on exertion.  He states he is unable to walk as far as he used when exercising, and when he over exerts himself, he reports having some mild chest pain and feeling lightheaded.  This resolves with rest and he denies any syncope with these events.

Medications

Metoprolol 50mg daily

Lisinopril 10mg daily

Simvastatin 30mg daily

Vital Signs

BP – 158/97

HR – 62

RR – 13

O2% – 100%

Physical exam

General – WN/WD male in NAD

Pulmonary – CTA without adventitial breath sounds

CV – Soft S2 with murmur over right 2nd intercostal space

PV – carotid pulse is weak and has a slow rise, murmur is appreciated

Neuro – No focal deficits

EKG

Questions

1. What is the next step in the management of this patient?
2. After the next step, what important variables must you specifically assess?

***LISTEN TO THE PODCAST HERE***

Anatomy

The pericardium consists of a double-layered semi-elastic sac that holds the heart in the mediastinum.  Basically, so the heart doesn’t flop around inside the thoracic cavity.  There should be a small amount of fluid (15-50mL) present to prevent adhesion of the pericardial sac to the heart.  It is then termed an effusion when it is more than the normal amount.  How much quantifies an effusion?  Doesn’t matter…. what does matter is how fast that fluid develops.  Because the pericardium is semi-elastic, it can accommodate and stretch over time if the accumulation is slow.  This would lead to a greater volume of fluid before symptoms occur.  If the fluid accumulates rapidly, less volume can produce profound effects due to the restrictive nature of the fibrous pericardium.

Etiology

• Infectious
  • Viral
  • Bacterial
  • Fungal
  • Parasitic
• Non-infectious
  • Neoplastic
  • Autoimmune/inflammatory
  • Trauma
  • Cardiac
  • Radiation
  • Metabolic

Signs and Symptoms

There are no reliable historical clues or physical exam findings that are specific to pericardial effusions.  They are helpful, though, to sort out the cause of the effusion. Common findings include:

• Fever
• Dyspnea
• Chest pain
• Tachycardia
• JVD
• Hepatomegaly
• Pulsus paradoxus
• Ewart’s Sign
  • Dullness to percussion, egophony, and bronchial breath sounds over the inferior angle of the left scapula
• Beck’s Triad
  • Hypotension
  • JVD
  • Muffled heart tones

http://www.medcomic.com

Work-Up

• EKG
  • Sinus tachycardia
  • Low voltage QRS (≤5mm in the 6 limb leads)
  • Electrical alternans
  • 

    Life In The Fastlane – o http://lifeinthefastlane.com/ecg-library/basics/low-qrs-voltage/

     
• Chest X-ray
  • Small effusions are generally not appreciated on radiography
  • Larger, chronic effusions may appear as an enlarged cardiac silhouette classically referred to as a “Water bottle heart”

  • 

    Radiopaedia

• Echocardiogram
  • Looking for anechoic stripe around the heart
    • < 1cm ≈ 100cc
    • 1-2cm ≈ 100-500cc
    • > 2cm ≈ >500cc

    • MASSIVE PERICARDIAL EFFUSION

      This is what 1 Liter of fluid in your pericardium looks like!#FOAMed pic.twitter.com/i3nOuWqE4U

      — Sam Ghali, M.D. (@EM_RESUS) January 24, 2017

  • 2D Apical 4-chamber is my view of choice
  • Severity can also be assessed by looking for:
    • RV collapse during diastole
    • LV collapse with increased EF
    • IVC dilation and loss of respiratory variations
  •  

Treatment

• Pericardiocentesis with catheter placement
  •  

  • Three-way stopcock is used to measure pericardial pressure
  • Fluid is then sequentially removed and pressure re-measured until < 5mmHg during inspiration
  •  

• Open surgical drainage via pericardial window if:
  • Fluid accumulates after catheter drainage
  • Effusion is loculated
  • Need for biopsy
  • Patient has coagulopathy
  •  

  •  

References

1. Braunwald E. Pericardial Disease. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015. http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&Sectionid=79743215. Accessed January 12, 2017.
2. Imazio M. Contemporary management of pericardial diseases. Current Opinion in Cardiology. 2012;27(3):308-17. [pubmed]
3. Levy PY, Corey R, Berger P. Etiologic diagnosis of 204 pericardial effusions. Medicine. 2003;82(6):385-91. [pubmed]
4. Permanyer-Miralda G. Acute pericardial disease: approach to the aetiologic diagnosis. Heart (British Cardiac Society). 2004;90(3):252-4. [pubmed]
5. Bruch C, Schmermund A, Dagres N. Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment. Journal of the American College of Cardiology. 2001;38(1):219-26. [pubmed]
6. Sternbach G. Claude Beck: cardiac compression triads. The Journal of Emergency Medicine. 1989;6(5):417-9. [pubmed]
7. Stanford University. Tamponade. Echocardiography in ICU. https://web.stanford.edu/group/ccm_echocardio/cgi-bin/mediawiki/index.php/Tamponade.
8. Adler Y, Charron P, Imazio M. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal. 2015;36(42):2921-64. [pubmed]
9. Gumrukcuoglu HA, Odabasi D, Akdag S, Ekim H. Management of Cardiac Tamponade: A Comperative Study between Echo-Guided Pericardiocentesis and Surgery-A Report of 100 Patients. Cardiology Research and Practice. 2011:197838. [pubmed]

Question

What are the 3 eponymous physical exam findings in patients with bacterial endocarditis and who were they named after?

Answers

Osler Nodes

• Painful, erythematous nodules of the hands and feet
• Named after Sir William Osler in 1908.

Janeway Lesions

• Nontender, erythematous or hemorrhagic macular or nodular lesions on the palms or soles
• Named after Theodore Caldwell Janeway in the late 1800s.

Roth Spots

• Retinal hemorrhages with white or pale centers.
• Named after Swiss pathologist Mortiz Roth in 1872

References

1. Osler W.  Chronic Infectious Endocarditis.  Quarterly Journal of Medicine.  1908;2:219-230.
2. Ruiz-García J, Canal-Fontcuberta I. Diagnosis of Active Infective Endocarditis from Examination of the Toes and Soles. The American Journal of Cardiology. 2016;118(7):1094. [pubmed]
3. Khanna N, Roy A, Bahl VK. Janeway lesions: an old sign revisited. Circulation. 2013;127(7):861. [pubmed]
4. Sethi K, Buckley J, de Wolff J. Splinter haemorrhages, Osler’s nodes, Janeway lesions and Roth spots: the peripheral stigmata of endocarditis. British Journal of Hospital Medicine. 2013;74(9):C139-42. [pubmed]

Happy 2017!!!  I apologize for the delay in having the pearls coming out, but life is life.  So here you go:

What are the 3 eponymous physical exam findings in patients with bacterial endocarditis and who were they named after?