CASE PRESENTATION

HPI: Ms. C. is a 67 year old female with past medical history significant for frequent exacerbations of chronic bronchitis secondary to tobacco abuse, hypercholesterolemia and hypothyroidism. She had a normal treadmill test and echocardiogram in 1994.

She presented to her PCP in early September 1999 with shortness of breath, dyspnea on exertion and occasional nocturnal dyspnea. She was treated with antibiotics for a presumed flair of bronchitis without relief of her symptoms.

HPI CONTINUED

She returned approximately 1 week later with complaints of occasional stabbing back pain and something in her chest pushing on her heart, new onset lower extremity edema and abdominal distension. ECG at that time revealed low voltage with no evidence of myocardial injury or ischemia; the low voltage was new compared to previous ECG. Diuretic therapy was initiated and the patient was referred to the pulmonary clinic. Chest X-ray done prior to the clinic visit revealed new cardiomegaly, bilateral pleural effusion and compressive atelectasis. She was then admitted to the Cardiology A service.

ALLERGIES: None

MEDICATIONS: Lipitor 10 mg P.O. q daySynthroid 0.01mg P.O. q dayECASA 325 mg P.O. q dayCentrum Silver 1 P.O. q day

SOCIAL: Significant for >100 pack-year history of tobacco.

FAMILY HX: Significant for non-premature CAD and hypertension.

PHYSICAL EXAM:

VS: P: 72R: 24SBP: 128 with an additional 40mm Hg paradoxusDBP: 70

NECK: Supple without LA, TM, JVD, or bruit. The carotid upstrokes were brisk bilaterally.

PHYSICAL EXAM CONTINUED

CHEST: Decreased breath sounds at the bases with bilateral dullness to percussion left greater than right, mid lung ronchi and anterior wheezes.

COR: Regular rhythm with no palpable PMI or lift. The heart tones were distant with S1 and S2

without definite murmurs, rubs or gallups.

PHYSICAL EXAM CONTINUED

ABD: Soft with normo-active bowel sounds, right upper quadrant tenderness and 4 cm of palpable liver below the costal margin.

EXT: Pulses 2+ in the upper and lower extremities bilaterally. Palmar cyanosis was noted along with 2+ pitting edema below the knee.

ELECTROCARDIOGRAM:

Sinus rhythm with a rate of 74, low voltage in both the limb and the precordial leads and nonspecific ST-T wave changes.

ECHOCARDIOGRAM:

2D echocardiography revealed normal left ventricular chamber size and adequate LV performance. A moderate to large circumferential pericardial effusion was present with evidence of bi-atrial collapse without right ventricular diastolic collapse. Pulse-wave doppler of the tricuspid and the mitral valve flow revealed no significant inspiratory or expiratory variation.

• PATHOPHYSIOLOGY

• SYMPTOMS

• CLINICAL SIGNS

• ELECTROCARDIOGRAM

• ECHOCARDIOGRAM

End Expiration Inspiration Expiration

15 mm 10 mm 20 mm

15 mm 14 mm 15 mm

15 mm 14 mm 15 mm

Pleural space

RV LV RV LV RV LV

Braunwald E. Atlas of Heart Diseases Vol 2. 1994: pp. 13.9

EXPIRATION INSPIRATION EXPIRATION

Blood

Pressure

130mmHg

100mmHg

70mmHg

Respiratory Variation of Blood Pressure in Cardiac Tamponade

Symptomatology of Cardiac Tamponade

• Chest pain– Oppressive precordial– Positional

• Dyspnea• Apprehension• Cough

• Dysphagia• Hoarseness• Singultus• Early Satiety• Nausea• Abdominal Pain

Symptoms of Ms. C.

• Fullness in chest pushing on her heart

• Stabbing quality chest pain

• Shortness of breath• Dyspnea on exertion

• Occasional nocturnal dyspnea

• Abdominal distension• Early satiety• Lower extremity

edema

Clinical Signs of Cardiac Tamponade

• General

– Anxious

– Apprehensive

– Ashen gray facies

– Cool perspiration

– Tachypnea

Clinical Signs of Cardiac Tamponade

• Tachycardia

• Tachypnea

• Jugular venous distension

• Peripheral Cyanosis

Clinical Signs of Cardiac Tamponade

• Quiet precordium with both inspection and palpation

• Impure muffled heart sounds

• Rub

• Bamberger-Pins-Ewart sign

– Variable dullness and bronchial breathing at one or both bases most frequently the left below the 9th rib and between the mid scapular line and the spine.

Clinical Signs of Cardiac Tamponade

• Pulsus Paradoxus

– First described by Kussmaul in 1873 as a palpable decrease or absence of the radial pulse during inspiration.

Kussmaul, A. Puls. Klin. Wchnschr. 1873: 10, 433-5, 445-9, 461-4.

• Place the patient in a position of comfort and conduct manometric studies during baseline respiration.

• Raise sphygmomanometer pressure until Korotkoff sounds disappear.

• Lower pressure slowly until first Korotkoff sounds are heard during early expiration with their disappearance during inspiration.

• Record this pressure.

• Very slowly lower pressure until Korotkoff sounds are heard throughout the respiratory cycle with even intensity.

• Record this pressure.

• The difference between the two recorded pressures is the Pulsus Pardoxus.

• Significant pulsus paradox is greater than or equal to 10% of the pressure at which all Korotkoff sounds are heard with even intensity.

Pulsus Paradoxus

• Pulsus Paradoxus is felt to be present when the paradoxus is greater than 10% of the pressure at which all Korotkoff sounds are heard with even intensity.

Spodick, D.H. Prog. Cardiov. Dis. 1967: 10,64-96.

Guberman et. al. 1981

Physical Finding Percentage present

Elevated JVP 100Pulsus Paradoxus 98Tachypnea 80Tachycardia 77SBP<100 36Decreased Heart Sounds 34Rub 29Rapidly falling BP 25

Physical findings in 56 patients diagnosed withCardiac Tamponade at the bedside.Circulation. 1981: 64, 633-9.

Physical findings in Ms. C.

• Apprehensive• Peripheral cyanosis• No JVD• Pulsus Paradoxus• Tachypnea• No palpable PMI or

lift

• Distant heart tones with S1 and S2

• Right upper quadrant tenderness

• 4cm of palpable liver below the costal margin

Other Etiologies of Pulsus Paradoxus

• Large pulmonary embolus

• Severe COPD exacerbation

• Labored respiration

• Constrictive pericarditis

• Restrictive cardiomyopathy

• Right ventricular infarction

• Circulatory shock

• Large pleural effusions

• Tense ascites

• Extreme obesity

Conditions in which Cardiac Tamponade presents without a Pulsus Paradoxus

• Septal Defect

• Severe Aortic Stenosis

• Severe Left Ventricular Dysfunction

– Cardiomyopathy

– Myocardial infarction

ECG Finding Sensitivity Specificity

Electrical Alternans 76 - 93 % 8 - 33 %

Low Voltage 99% 25%

P-R depression 86% 42%

Electrocardiographic diagnosis of Cardiac Tamponade

187 patients with echocardiographically diagnosed pericardial effusion.

Eisenberg, M.J. et. al. Chest. 1996: 110, 318-24.

Etiologies of Electrical Alternans

• Pericardial effusion• Constrictive pericarditis• Tension pneumothorax• Myocardial dysfunction

– Severe cardiomyopathy– Myocardial infarction

ECHOCARDIOGRAPHY

Commonly seen views in 2 dimensional Echocardiography

• Parasternal Long Axis

• Parasternal Short Axis

• Apical 4 Chamber

• Subcoastal

• IVC

Insert Echo Here

Insert 35mm slide

Echocardiographic Findings Seen In Cardiac Tamponade

• Pericardial effusion• Right atrial collapse• Right ventricular diastolic collapse• Swinging heart• Respiratory variation of tricuspid and mitral valve

flow velocities

Insert echo here

Echocardiographic findings of Ms. C.

• PRESENT

• A moderate to large circumferential pericardial effusion.

• Normal left ventricular chamber size and function

• Bi-atrial collapse

• ABSENT

• Right ventricular diastolic collapse.

• Significant inspiratory/expiratory variation of the tricuspid or mitral valve flow patterns.

Time: hours, days, weeks, months

Increasing Pericardial Effusion

COMPENSATED TAMPONADE

120mmHg

30mmHg

0mmHg

Spodick, D.H. Prog. Cardiov. Dis. 1967: 10, 64-96

Pressure

Systolic Blood Pressure

Venous Pressure

Mean RA Pressure

RV Diastolic Pressure

Schiller, et. al. 1977

• In a retrospective analysis the presence of Right

Ventricular Diastolic Collapse (RVDC) in 17 patients

with Cardiac Tamponade.

Circulation. 1977, 56: 774-9.

Schiller, et. al. 1977

• RESULTS:– Sixteen of the 17 patients were found to have RVDC.

– The one patient without RVDC had severe chronic obstructive pulmonary disease (COPD).

• CONCLUSION:– The evaluation of right ventricular diastolic collapse may

be clinically useful in the diagnosis and monitoring of Cardiac Tamponade except in patients with RVH and pulmonary hypertension.

Circulation 1977, 56: 774-9

Gillam, et. al. 1983

• With the advancement of 2D imaging techniques right atrial collapse (RAC) was identified in patients with Cardiac Tamponade. The sensitivity and specificity of RAC to identify patients with Cardiac Tamponade.

• The echocardiograms of 123 patients with moderate and large pericardial effusions, 19 with clinically diagnosed Cardiac Tamponade, were examined for the presence of RAC

Circulation. 1983, 68: 294-301.

Gillam, et. al. 1983

• RESULTS:– Right atrial collapse was noted in 19 of the 19

patients with Cardiac Tamponade.– Right atrial collapse was noted in 19 of the 104

patients with non hemodynamically significant moderate and large pericardial effusions.

– Sensitivity = 100%– Specificity = 84%

Circulation 1983, 68: 294-301.

Gilliam, et. al. 1983

• RESULTS:– The authors noted that the greater the duration

of the right atrial collapse, the more specific the finding became for the identification of patients with Cardiac Tamponade. The specificity rose to 100% when the duration of atrial collapse was > 34% of the cycle length.

Circulation 1983, 68: 294-301.

Gillam, et. al. 1983

• CONCLUSION:– Prolonged right atrial collapse is a useful

marker of Cardiac Tamponade that may aid in the diagnosis of patients who do not have classic physical findings of Cardiac Tamponade.

Circulation. 1983, 68: 294-301.

Singh, et. al. 1984• The sensitivity and specificity of right atrial collapse

vs, right ventricular diastolic collapse in the identification of patients with Cardiac Tamponade. Utilizing echocardiographic and invasive hemodynamic monitoring, 16 patients refered for therapeutic or diagnostic pericardiocentesis were assessed for the presence of Cardiac Tamponade and right atrial and right ventricular diastolic collapse.

Circulation. 1984, 70: 966-71.

Singh, et. al. 1984

Condition (n)RVDC

(n)RAC(n)

EffusionVolume cc

Tamponade 12 12 9 180-2100

Compensated 3 0 0 200-850

Tamponadewith PulmonaryHTN

1 0 0 850

RESULTS:

Circulation. 1984, 70: 966-71.

Singh, et. al. 1984• CONCLUSIONS:

– Right ventricular diastolic collapse is a highly sensitive and specific indicator of Cardiac Tamponade.

– Right atrial collapse although specific for Cardiac Tamponade was less sensitive for the detection of Cardiac Tamponade.

– Right heart collapse may not be seen in patients with pulmonary HTN and Cardiac Tamponade.

Circulation 1984, 70: 966-71.

Levine, et. al. 1991

• 50 patients with pericardial effusions were given an echocardiographic diagnosis of Cardiac Tamponade if in the presence of pericardial effusion either right atrial collapse or right ventricular diastolic collapse was present.

• Patients diagnosed with echocardiographic Cardiac Tamponade were taken to pericardiocentesis with invasive hemodynamic monitoring of right atrial, intrapericardial and pulmonary cappilary wedge pressure.

JACC. 1991. 17: 59-65.

Levine, et. al. 1991

FINDINGLevine et. al.

(%)Guberman et. al.

(%)

JVD 74 100

Pulsus Paradoxus 20 mmHg 36 77

Heart rate >100 74 77

SBP <100 14 36Distant Heart Tones 24 24

Hepatomegaly 28 55

RESULTS:

JACC. 1991. 17: 59-65.

Levine, et. al. 1991• CONCLUSION:

– Patients with pericardial effusion and echocardiographic findings of right atrial collapse and or right ventricular diastolic collapse experience improvement of hemodynamic parameters with pericardiocentesis.

– These findings may be useful in detecting patients with pre-Tamponade physiology and may allow for early intervention to prevent the development of Cardiac Tamponade.

JACC. 1991. 17: 59-65.

Appleton, et. al.

• Using pulsed wave doppler ultrasound, the variation of the blood flow velocities across the tricuspid and mitral valves in 21 patients with pericardial effusions was assessed and compared with 21 controls. Of the patients with pericardial effusion, 7 patients were clinically diagnosed with Cardiac Tamponade while the remaining 14 had assymptomatic effusions.

JACC. 1988. 11: 1020-30.

Appleton, et. al.

EFFUSION (n)

PulsusParadoxus

mm Hg

Right AtrialPressuremm Hg

Respiratory variationof (MV) and (TV)

flow velocity

NONE 21 0 0 +Present with NOhemodynamicsignificance

0 0 +

Present with MILDhemodynamicsignificance

13 11 ++

Present withCardiac Tamponade 7 29 15 +++

JACC. 1988. 11: 1020-30.

14

Appleton, et. al.

• CONCLUSION– Pulsed wave doppler ultrasound of the tricuspid

and mitral valve flow may be useful in identifying and grading the severity of hemodynamic decompensation in patients with “asymptomatic” pericardial effusions.

Causes of Cardiac Tamponade

• Malignancy• Idiopathic pericarditis• Uremia• Bacterial infections• Anticoagulation• Dissecting aneurysm• Diagnostic proceedures

• Tuberculosis• Postpericardotomy• Trauma• Connective Tissue

Disease• Radiation• Myxedema

CONCLUSIONS

• Physical findings seen in Cardiac Tamponade– Elevated JVP

– Pulsus Paradoxus

– Tachypnea

– Tachycardia

– SBP < 100

– Rub

– Distant heart sounds

– Rapidly falling BP

– Peripheral Cyanosis

CONCLUSIONS

• Echocardiographic findings in Cardiac Tamponade– Pericardial effusion

– Right atrial collapse

– Right ventricular diastolic collapse

– Swinging heart

– Respiratory variation of the flow velocities across the tricuspid and mitral valves

CONCLUSIONS

• There is a continuum of patients with pericardial effusion from compensated to decompensated tamponade. Echocardiography may be helpful in the grading of severity of hemodynamic compromise, potentially identifying patients without signs of tamponade but who may benefit from urgent pericardiocentesis.

CONCLUSIONS

• Several pathologic conditions such as right ventricular hypertrophy or pulmonary hypertension, valvular abnormalities, septal defects etc. may result in no echocardiographic findings of hemodynamic compromise, despite its presence in patients with pericardial effusion.

CONCLUSIONS

• The gold standard for the diagnosis of pericardial effusion is echocardiography.

• The diagnosis of Cardiac Tamponade is based solely on PHYSICAL EXAM.