CASE PRESENTATION

1
(No Transcript)
2
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.
3
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.
4
ALLERGIES None MEDICATIONS Lipitor 10 mg
P.O. q day Synthroid 0.01mg P.O. q
day ECASA 325 mg P.O. q day Centrum Silver
1 P.O. q day SOCIAL Significant for gt100
pack-year history of tobacco. FAMILY HX
Significant for non-premature CAD and
hypertension.
5
PHYSICAL EXAM VS P 72 R 24 SBP 128
with an additional 40mm Hg paradoxus DBP
70 NECK Supple without LA, TM, JVD, or bruit.
The carotid upstrokes were brisk
bilaterally.
6
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.
7
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.
8
ELECTROCARDIOGRAM Sinus rhythm with a rate of
74, low voltage in both the limb and the
precordial leads and nonspecific ST-T wave
changes.
9
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.
10

• PATHOPHYSIOLOGY
• SYMPTOMS
• CLINICAL SIGNS
• ELECTROCARDIOGRAM
• ECHOCARDIOGRAM

11
End Expiration Inspiration
Expiration
Pleural space
15 mm 10 mm 20 mm
15 mm 14
mm 15 mm
RV LV RV LV
RV LV
15 mm 14 mm 15 mm
Braunwald E. Atlas of Heart Diseases Vol 2. 1994
pp. 13.9
12
Respiratory Variation of Blood Pressure in
Cardiac Tamponade
B l o o d P r e s s u r e
130 mmHg
100 mmHg
70 mmHg
EXPIRATION
INSPIRATION
EXPIRATION
13
Symptomatology of Cardiac Tamponade

• Chest pain
• Oppressive precordial
• Positional
• Dyspnea
• Apprehension
• Cough

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

14
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

15
Clinical Signs of Cardiac Tamponade

• General
• Anxious
• Apprehensive
• Ashen gray facies
• Cool perspiration
• Tachypnea

16
Clinical Signs of Cardiac Tamponade

• Tachycardia
• Tachypnea
• Jugular venous distension
• Peripheral Cyanosis

17
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.

18
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.
19

• 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.

20
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.
21
Guberman et. al. 1981
Physical Finding Percentage present
Elevated JVP 100 Pulsus Paradoxus
98 Tachypnea 80 Tachycardia
77 SBPlt100 36 Decreased Heart Sounds
34 Rub 29 Rapidly falling BP 25
Physical findings in 56 patients diagnosed
withCardiac Tamponade at the bedside. Circulation.
1981 64, 633-9.
22
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

23
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

24
Conditions in which Cardiac Tamponade presents
without a Pulsus Paradoxus

• Septal Defect
• Severe Aortic Stenosis
• Severe Left Ventricular Dysfunction
• Cardiomyopathy
• Myocardial infarction

25
Electrocardiographic diagnosis of Cardiac
Tamponade
ECG Finding Sensitivity
Specificity Electrical Alternans 76 - 93
8 - 33 Low Voltage 99
25 P-R depression 86
42
187 patients with echocardiographically diagnosed
pericardial effusion. Eisenberg, M.J. et. al.
Chest. 1996 110, 318-24.
26
Etiologies of Electrical Alternans

• Pericardial effusion
• Constrictive pericarditis
• Tension pneumothorax
• Myocardial dysfunction
• Severe cardiomyopathy
• Myocardial infarction

27
ECHOCARDIOGRAPHY
28
Commonly seen views in 2 dimensional
Echocardiography

• Parasternal Long Axis
• Parasternal Short Axis
• Apical 4 Chamber
• Subcoastal
• IVC

29
Insert Echo Here
30
Insert 35mm slide
31
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

32
Insert echo here
33
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.

34
120 mmHg
Time hours, days, weeks, months
COMPENSATED TAMPONADE
P r e s s u r e
Systolic Blood Pressure
30 mmHg
Venous Pressure
Mean RA Pressure
RV Diastolic Pressure
0 mmHg
Increasing Pericardial Effusion
Spodick, D.H. Prog. Cardiov. Dis. 1967 10, 64-96
35
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.
36
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
37
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.
38
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.
39
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 gt 34 of the cycle length.

Circulation 1983, 68 294-301.
40
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.
41
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.
42
Singh, et. al. 1984
RESULTS
Circulation. 1984, 70 966-71.
43
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.
44
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.
45
Levine, et. al. 1991
RESULTS
JACC. 1991. 17 59-65.
46
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.
47
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.
48
Appleton, et. al.
14
JACC. 1988. 11 1020-30.
49
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.

50
Causes of Cardiac Tamponade

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

• Tuberculosis
• Postpericardotomy
• Trauma
• Connective Tissue Disease
• Radiation
• Myxedema

51
CONCLUSIONS

• Physical findings seen in Cardiac Tamponade
• Elevated JVP
• Pulsus Paradoxus
• Tachypnea
• Tachycardia
• SBP lt 100
• Rub
• Distant heart sounds
• Rapidly falling BP
• Peripheral Cyanosis

52
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

53
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.

54
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.

55
CONCLUSIONS

• The gold standard for the diagnosis of
  pericardial effusion is echocardiography.
• The diagnosis of Cardiac Tamponade is based
  solely on PHYSICAL EXAM.