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  1. 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.
  2. 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.
  3. 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 >100 pack-year history of tobacco. FAMILY HX: Significant for non-premature CAD and hypertension.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 10. <ul><li>PATHOPHYSIOLOGY </li></ul><ul><li>SYMPTOMS </li></ul><ul><li>CLINICAL SIGNS </li></ul><ul><li>ELECTROCARDIOGRAM </li></ul><ul><li>ECHOCARDIOGRAM </li></ul>
  10. 11. 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
  11. 12. EXPIRATION INSPIRATION EXPIRATION B l o o d P r e s s u r e 130 mmHg 100 mmHg 70 mmHg Respiratory Variation of Blood Pressure in Cardiac Tamponade
  12. 13. Symptomatology of Cardiac Tamponade <ul><li>Chest pain </li></ul><ul><ul><li>Oppressive precordial </li></ul></ul><ul><ul><li>Positional </li></ul></ul><ul><li>Dyspnea </li></ul><ul><li>Apprehension </li></ul><ul><li>Cough </li></ul><ul><li>Dysphagia </li></ul><ul><li>Hoarseness </li></ul><ul><li>Singultus </li></ul><ul><li>Early Satiety </li></ul><ul><li>Nausea </li></ul><ul><li>Abdominal Pain </li></ul>
  13. 14. Symptoms of Ms. C. <ul><li>Fullness in chest pushing on her heart </li></ul><ul><li>Stabbing quality chest pain </li></ul><ul><li>Shortness of breath </li></ul><ul><li>Dyspnea on exertion </li></ul><ul><li>Occasional nocturnal dyspnea </li></ul><ul><li>Abdominal distension </li></ul><ul><li>Early satiety </li></ul><ul><li>Lower extremity edema </li></ul>
  14. 15. Clinical Signs of Cardiac Tamponade <ul><li>General </li></ul><ul><ul><li>Anxious </li></ul></ul><ul><ul><li>Apprehensive </li></ul></ul><ul><ul><li>Ashen gray facies </li></ul></ul><ul><ul><li>Cool perspiration </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul>
  15. 16. Clinical Signs of Cardiac Tamponade <ul><li>Tachycardia </li></ul><ul><li>Tachypnea </li></ul><ul><li>Jugular venous distension </li></ul><ul><li>Peripheral Cyanosis </li></ul>
  16. 17. Clinical Signs of Cardiac Tamponade <ul><li>Quiet precordium with both inspection and palpation </li></ul><ul><li>Impure muffled heart sounds </li></ul><ul><li>Rub </li></ul><ul><li>Bamberger-Pins- Ewart sign </li></ul><ul><ul><li>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. </li></ul></ul>
  17. 18. Clinical Signs of Cardiac Tamponade <ul><li>Pulsus Paradoxus </li></ul><ul><ul><li>First described by Kussmaul in 1873 as a palpable decrease or absence of the radial pulse during inspiration. </li></ul></ul>Kussmaul, A. Puls. Klin. Wchnschr. 1873: 10, 433-5, 445-9, 461-4.
  18. 19. <ul><li>Place the patient in a position of comfort and conduct manometric studies during baseline respiration. </li></ul><ul><li>Raise sphygmomanometer pressure until Korotkoff sounds disappear. </li></ul><ul><li>Lower pressure slowly until first Korotkoff sounds are heard during early expiration with their disappearance during inspiration. </li></ul><ul><li>Record this pressure. </li></ul><ul><li>Very slowly lower pressure until Korotkoff sounds are heard throughout the respiratory cycle with even intensity. </li></ul><ul><li>Record this pressure. </li></ul><ul><li>The difference between the two recorded pressures is the Pulsus Pardoxus. </li></ul><ul><li>Significant pulsus paradox is greater than or equal to 10% of the pressure at which all Korotkoff sounds are heard with even intensity. </li></ul>
  19. 20. Pulsus Paradoxus <ul><li>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 . </li></ul>Spodick, D.H. Prog. Cardiov. Dis. 1967: 10,64-96.
  20. 21. Guberman et. al. 1981 Physical Finding Percentage present Elevated JVP 100 Pulsus Paradoxus 98 Tachypnea 80 Tachycardia 77 SBP<100 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.
  21. 22. Physical findings in Ms. C. <ul><li>Apprehensive </li></ul><ul><li>Peripheral cyanosis </li></ul><ul><li>No JVD </li></ul><ul><li>Pulsus Paradoxus </li></ul><ul><li>Tachypnea </li></ul><ul><li>No palpable PMI or lift </li></ul><ul><li>Distant heart tones with S1 and S2 </li></ul><ul><li>Right upper quadrant tenderness </li></ul><ul><li>4cm of palpable liver below the costal margin </li></ul>
  22. 23. Other Etiologies of Pulsus Paradoxus <ul><li>Large pulmonary embolus </li></ul><ul><li>Severe COPD exacerbation </li></ul><ul><li>Labored respiration </li></ul><ul><li>Constrictive pericarditis </li></ul><ul><li>Restrictive cardiomyopathy </li></ul><ul><li>Right ventricular infarction </li></ul><ul><li>Circulatory shock </li></ul><ul><li>Large pleural effusions </li></ul><ul><li>Tense ascites </li></ul><ul><li>Extreme obesity </li></ul>
  23. 24. Conditions in which Cardiac Tamponade presents without a Pulsus Paradoxus <ul><li>Septal Defect </li></ul><ul><li>Severe Aortic Stenosis </li></ul><ul><li>Severe Left Ventricular Dysfunction </li></ul><ul><ul><li>Cardiomyopathy </li></ul></ul><ul><ul><li>Myocardial infarction </li></ul></ul>
  24. 25. 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.
  25. 26. Etiologies of Electrical Alternans <ul><li>Pericardial effusion </li></ul><ul><li>Constrictive pericarditis </li></ul><ul><li>Tension pneumothorax </li></ul><ul><li>Myocardial dysfunction </li></ul><ul><ul><li>Severe cardiomyopathy </li></ul></ul><ul><ul><li>Myocardial infarction </li></ul></ul>
  27. 28. Commonly seen views in 2 dimensional Echocardiography <ul><li>Parasternal Long Axis </li></ul><ul><li>Parasternal Short Axis </li></ul><ul><li>Apical 4 Chamber </li></ul><ul><li>Subcoastal </li></ul><ul><li>IVC </li></ul>
  28. 29. Insert Echo Here
  29. 30. Insert 35mm slide
  30. 31. Echocardiographic Findings Seen In Cardiac Tamponade <ul><li>Pericardial effusion </li></ul><ul><li>Right atrial collapse </li></ul><ul><li>Right ventricular diastolic collapse </li></ul><ul><li>Swinging heart </li></ul><ul><li>Respiratory variation of tricuspid and mitral valve flow velocities </li></ul>
  31. 32. Insert echo here
  32. 33. Echocardiographic findings of Ms. C. <ul><li>PRESENT </li></ul><ul><li>A moderate to large circumferential pericardial effusion. </li></ul><ul><li>Normal left ventricular chamber size and function </li></ul><ul><li>Bi-atrial collapse </li></ul><ul><li>ABSENT </li></ul><ul><li>Right ventricular diastolic collapse. </li></ul><ul><li>Significant inspiratory/expiratory variation of the tricuspid or mitral valve flow patterns. </li></ul>
  33. 34. Time: hours, days, weeks, months Increasing Pericardial Effusion COMPENSATED TAMPONADE 120 mmHg 30 mmHg 0 mmHg Spodick, D.H. Prog. Cardiov. Dis. 1967: 10, 64-96 P r e s s u r e Systolic Blood Pressure Venous Pressure Mean RA Pressure RV Diastolic Pressure
  34. 35. Schiller, et. al. 1977 <ul><li>In a retrospective analysis the presence of Right </li></ul><ul><li>Ventricular Diastolic Collapse (RVDC) in 17 patients </li></ul><ul><li>with Cardiac Tamponade. </li></ul>Circulation. 1977, 56: 774-9.
  35. 36. Schiller, et. al. 1977 <ul><li>RESULTS: </li></ul><ul><ul><li>Sixteen of the 17 patients were found to have RVDC. </li></ul></ul><ul><ul><li>The one patient without RVDC had severe chronic obstructive pulmonary disease (COPD). </li></ul></ul><ul><li>CONCLUSION: </li></ul><ul><ul><li>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. </li></ul></ul>Circulation 1977, 56: 774-9
  36. 37. Gillam, et. al. 1983 <ul><li>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. </li></ul><ul><li>The echocardiograms of 123 patients with moderate and large pericardial effusions, 19 with clinically diagnosed Cardiac Tamponade, were examined for the presence of RAC </li></ul>Circulation. 1983, 68: 294-301.
  37. 38. Gillam, et. al. 1983 <ul><li>RESULTS: </li></ul><ul><ul><li>Right atrial collapse was noted in 19 of the 19 patients with Cardiac Tamponade. </li></ul></ul><ul><ul><li>Right atrial collapse was noted in 19 of the 104 patients with non hemodynamically significant moderate and large pericardial effusions. </li></ul></ul><ul><ul><li>Sensitivity = 100% </li></ul></ul><ul><ul><li>Specificity = 84% </li></ul></ul><ul><ul><li>Circulation 1983, 68: 294-301. </li></ul></ul>
  38. 39. Gilliam, et. al. 1983 <ul><li>RESULTS: </li></ul><ul><ul><li>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. </li></ul></ul>Circulation 1983, 68: 294-301.
  39. 40. Gillam, et. al. 1983 <ul><li>CONCLUSION: </li></ul><ul><ul><li>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. </li></ul></ul>Circulation. 1983, 68: 294-301.
  40. 41. Singh, et. al. 1984 <ul><li>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. </li></ul><ul><ul><li>Circulation. 1984, 70: 966-71. </li></ul></ul>
  41. 42. Singh, et. al. 1984 RESULTS: Circulation. 1984, 70: 966-71.
  42. 43. Singh, et. al. 1984 <ul><li>CONCLUSIONS: </li></ul><ul><ul><li>Right ventricular diastolic collapse is a highly sensitive and specific indicator of Cardiac Tamponade. </li></ul></ul><ul><ul><li>Right atrial collapse although specific for Cardiac Tamponade was less sensitive for the detection of Cardiac Tamponade. </li></ul></ul><ul><ul><li>Right heart collapse may not be seen in patients with pulmonary HTN and Cardiac Tamponade. </li></ul></ul>Circulation 1984, 70: 966-71.
  43. 44. Levine, et. al. 1991 <ul><li>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. </li></ul><ul><li>Patients diagnosed with echocardiographic Cardiac Tamponade were taken to pericardiocentesis with invasive hemodynamic monitoring of right atrial, intrapericardial and pulmonary cappilary wedge pressure. </li></ul>JACC. 1991. 17: 59-65.
  44. 45. Levine, et. al. 1991 RESULTS: JACC. 1991. 17: 59-65.
  45. 46. Levine, et. al. 1991 <ul><li>CONCLUSION: </li></ul><ul><ul><li>Patients with pericardial effusion and echocardiographic findings of right atrial collapse and or right ventricular diastolic collapse experience improvement of hemodynamic parameters with pericardiocentesis. </li></ul></ul><ul><ul><li>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. </li></ul></ul>JACC. 1991. 17: 59-65.
  46. 47. Appleton, et. al. <ul><li>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. </li></ul>JACC. 1988. 11: 1020-30.
  47. 48. Appleton, et. al. JACC. 1988. 11: 1020-30. 14
  48. 49. Appleton, et. al. <ul><li>CONCLUSION </li></ul><ul><ul><li>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. </li></ul></ul>
  49. 50. Causes of Cardiac Tamponade <ul><li>Malignancy </li></ul><ul><li>Idiopathic pericarditis </li></ul><ul><li>Uremia </li></ul><ul><li>Bacterial infections </li></ul><ul><li>Anticoagulation </li></ul><ul><li>Dissecting aneurysm </li></ul><ul><li>Diagnostic proceedures </li></ul><ul><li>Tuberculosis </li></ul><ul><li>Postpericardotomy </li></ul><ul><li>Trauma </li></ul><ul><li>Connective Tissue Disease </li></ul><ul><li>Radiation </li></ul><ul><li>Myxedema </li></ul>
  50. 51. CONCLUSIONS <ul><li>Physical findings seen in Cardiac Tamponade </li></ul><ul><ul><li>Elevated JVP </li></ul></ul><ul><ul><li>Pulsus Paradoxus </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>SBP < 100 </li></ul></ul><ul><ul><li>Rub </li></ul></ul><ul><ul><li>Distant heart sounds </li></ul></ul><ul><ul><li>Rapidly falling BP </li></ul></ul><ul><ul><li>Peripheral Cyanosis </li></ul></ul>
  51. 52. CONCLUSIONS <ul><li>Echocardiographic findings in Cardiac Tamponade </li></ul><ul><ul><li>Pericardial effusion </li></ul></ul><ul><ul><li>Right atrial collapse </li></ul></ul><ul><ul><li>Right ventricular diastolic collapse </li></ul></ul><ul><ul><li>Swinging heart </li></ul></ul><ul><ul><li>Respiratory variation of the flow velocities across the tricuspid and mitral valves </li></ul></ul>
  52. 53. CONCLUSIONS <ul><li>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. </li></ul>
  53. 54. CONCLUSIONS <ul><li>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. </li></ul>
  54. 55. CONCLUSIONS <ul><li>The gold standard for the diagnosis of pericardial effusion is echocardiography. </li></ul><ul><li>The diagnosis of Cardiac Tamponade is based solely on PHYSICAL EXAM. </li></ul>