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The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.

We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.

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Patient Summary

A woman in her mid-70s presented to clinic with subacute onset shortness of breath. Her past medical history includes metastatic breast cancer s/p mastectomy, chemo/radiation, and hormonal therapy. Exam notable for tachycardia without hypoxia, muffled heart sounds, JVD with Kussmaul’s sign, and 1+ LE edema. The patient was sent to the ED for evaluation of possible pericardial effusion. CTA chest in ED did not demonstrate a PE, but did show bilateral pleural effusions, and a moderate pericardial effusion with evidence of metastatic disease extending into the mediastinum. TTE obtained showing normal LVEF, moderate pericardial effusion with thickened pericardium, and significant respirophasic tricuspid and mitral inflow variations. Pulsus paradoxus was manually checked and found to be 16 mmHg. 

Due to concern for cardiac tamponade, she was taken to the cath lab for a RHC and pericardiocentesis. RHC prior to pericardiocentesis showed elevated left and ride sided filling pressures, blunted y decent in the RA, and equalization of diastolic pressures. Pericardiocentesis yielded 200 cc of bloody fluid with improvement, but continued elevation, in her L and R sided pressures. Blunted y decent did give way to a now rapid y descent concerning for constrictive pericarditis. She then underwent a cardiac MRI showing respirophasic septal motion suggestive of interventricular dependence and >1 cm thick pericardium with LGE c/w inflammation. Unfortunately, cytology of pericardial fluid was c/w a malignant effusion and despite treatment with a few months of anti-inflammatory therapy her symptoms did not improve. She then underwent a pericardial stripping with subsequent resolution of her symptoms. As her symptoms and hemodynamics were related to both the effusion and constriction, she was ultimately diagnosed with effusive constrictive pericarditis. 

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Case Media

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Episode Schematics & Teaching

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The CardioNerds 5! – 5 major takeaways from the #CNCR case

1. What is cardiac tamponade, what causes it, and how does it lead to hypotension? 
   • The pericardial cavity typically holds 50 cc of fluid, which acts as a lubricant for the beating heart. Accumulation of additional fluid in this space can increase intrapericardial pressure and cause compression of the cardiac chambers. Rapid accumulation of small amounts of fluid can lead to tamponade as the pericardium will not have time to expand. In instances of a slow accumulation, large volumes might accumulate before tamponade occurs as the pericardium will expand to accommodate the fluid. 
   • Many conditions can cause tamponade. The most common are malignancy (>50% of all cases), infection (viral most common, though TB is common in developing countries), trauma/post procedural (e.g. cardiac surgery, pacemaker placement), uremia, rheumatologic (e.g. SLE, RA), drug induced (e.g. hydralazine, procainamide), and radiation-induced. Note the epidemiology is different from causes of pericarditis without tamponade. 
   • Increasing pericardial pressure leads to a compensatory increase in diastolic pressure in all chambers until they become similar to the pericardial pressure. This happens more rapidly in the right side of the heart due to lower diastolic pressures in these chambers. The elevated intracardiac diastolic pressures reduces the driving pressure for filling (Flow = pressure gradient / resistance and so ↓∆P = ↓Flow ); this reduces diastolic filling (preload) and a causes a compensatory increase in contractility and heart rate to maintain stroke volume and cardiac output (CO = HR x SV so as SV decreases, the HR increases). As diastolic filling continues to decrease the transmural distending pressure of the RA and RV will also decrease and eventually lead to diastolic collapse.  
   • As reviewed in previous posts (Mayo and Tennessee), as ventricular interdependence worsens, left ventricular cardiac output can be further compromised and contribute to hypotension. Enjoy Episodes #58 and #59 discussing constrictive pericarditis. 
     
2. Tamponade can be a difficult clinical diagnosis. How is it diagnosed, what are some of the basic clinical markers of cardiac tamponade, and which are most useful in diagnosis? 
   • Though definitive diagnosis requires pericardiocentesis with hemodynamic and clinical improvement, there are many features that are useful for identifying tamponade. Unfortunately, no one clinical or echocardiographic feature is diagnostic of tamponade and a clinical diagnosis relies on the assimilation of multiple abnormalities. 
   • Beck’s triad of hypotension, jugular venous distension, and muffled heart sounds 
     • Originally described in 1935 by Dr. Claude Beck, it focuses on these signs of tamponade, which were derived from surgical patients and are more characteristic of acute tamponade from trauma or cardiac/aortic rupture. Though ~90% of patients in trauma series have at least one of these findings, only about ~30% have all three. Muffled heart sounds and hypotension are both poorly sensitive findings, making the sensitivity of the overall triad poor. 
   • Tachycardia 
     • Though not specific, tachycardia is a very sensitive marker of cardiac tamponade as in some series it is present in 81-100% of patients with a pooled sensitivity of around 80%. 
   • Elevated JVP 
     • Elevated JVP is one of the key findings in tamponade and is present in almost all cases. Increased early diastolic pressure limits filling during this period, blunting the y descent. Studies show sensitivity ranges from 53-88% with a pooled average of 75%.  
   • Kussmaul’s sign 
     • Kussmaul’s sign is the failure of the JVP to fall during inspiration. This is rarely seen in cardiac tamponade; it is much more common in constrictive pericarditis, where it can be seen in up to 50% of cases. 
   • EKG findings of low voltage or electrical alternans  
     • As fluid builds around the heart it can insulate the heart’s electrical activity from the EKG leads leading to low voltage on the EKG. Additionally, as the heart oscillates within the distended pericardial sack, the QRS amplitude can oscillate, which is called electrical alternans. As low voltage can be seen in a variety of conditions it is poorly specific, but sensitivity is around 70%. Electrical alternans on the other hand is rarely seen in tamponade, but if present it has a PPV > 95%. 
   • Enlarged cardiac silhouette on CXR 
     • The cardiac silhouette on a CXR does not appear enlarged until a pericardial effusion is around 200 mL. Given that many conditions also cause an enlarged silhouette it has both poor sensitivity and specificity. 
       
3. What is a pulsus paradoxus and what is the pathophysiology? How do you measure it and how clinically useful is it in the diagnosis of tamponade? What conditions might cause it to be absent in tamponade? 
   • In a normal heart, inspiration decreases intrathoracic pressure, thus increasing right-sided filling. As the RV stretches to accommodate the volume, the interventricular septum bulges towards the left causing reduced left-sided filling and therefore a drop in blood pressure (this is ventricular interdependence). During expiration the opposite happens and the blood pressure increases. This process is exaggerated in cardiac tamponade as both ventricles are completing for a limited amount of space, which leads to a larger than normal drop in blood pressure during inspiration. This exaggerated drop is called pulsus paradoxus (though pulsus exaggeratus may be a better name!).  
   • Pulsus paradoxus can be measured with a blood pressure cuff while a patient is breathing normally.  First the cuff is inflated until no Korotkoff sounds can be heard and then slowly deflated until Korotkoff sounds can only be heard during expiration (say 120 mmHg). The cuff is further deflated until sounds can be heard throughout the respiratory cycle (say 100 mmHg). If the difference in these two numbers (here 20 mmHg) is ≥ 10 mmHg it is deemed a clinically significant pulsus paradoxus. 
   • Pulsus paradoxus is an important finding in cardiac tamponade as a pulsus > 10 mmHg occurs in almost all patients with tamponade. A cutoff of 12 mmHg improves specificity and is 98% sensitive and 83% specific in patients with a known pericardial effusion. 
   • There are a few situations where a patient might be in tamponade, but might not have pulsus paradoxus. They include extreme hypotension, low pressure tamponade (e.g., dehydration), atrial septal defects, severe AI, loculated/local effusions, and a very poorly compliant LV or RV. 
   • Pulsus can also be present in patients without pericardial disease, including (but not limited to) patients with COPD or asthma, obstructive sleep apnea, and significant obesity.  
     
4. What are the signs of cardiac tamponade on echo and RHC? 
   • Echocardiography is the primary imaging modality to evaluate for signs of tamponade. Consistent with the previously described pathophysiology, signs of tamponade on TTE include early diastolic collapse of the RV free wall, diastolic collapse of the RA, swinging of the heart in the pericardial sac, dilated IVC without collapse, a >60% increase in TV flow and >30% decrease in MV flow during inspiration (more specific for tamponade than the cut-offs of 40% and 25% seen in constriction), and septal deviation into the LV with inspiration. Remember to differentiate the size and composition of the effusion. Of these findings early diastolic collapse of the RV free wall is most specific and dilation of the IVC, and late diastolic collapse of the RA are most sensitive.  
   • Though RHC is not routinely performed for the diagnosis of tamponade, there are a few key findings that are relevant. As discussed above, equalization of diastolic pressures, pulsus paradoxus, and pulsus alternans can all be seen on the pressure tracings and measurements in a RHC. Additionally, the RA waveform can show a blunted y descent as discussed above. 
     
5. What is effusive constrictive pericarditis (ECP) and how does one differentiate it from tamponade or constrictive pericarditis? How is it treated? 
   • Effusive constrictive pericarditis is a clinical entity comprised of both decreased pericardial compliance and a hemodynamically significant pericardial effusion. This is often found when patients undergo pericardiocentesis for suspected tamponade only to reveal continued elevation in RA pressures and constrictive physiology. Some use a cut-off of a failure to fall by 50% or to less than 10 mmHg in the RA.  
   • Though ECP can initially present with some signs of constriction (elevated medial e’ velocities) true constrictive pericarditis should not have signs of a hemodynamically significant effusion (RA/RV diastolic collapse, blunted y descent) and is much less likely to have pulsus paradoxus. 
   • Though there is no uniform consensus on how to treat ECP, it is generally agreed that anti-inflammatory medications are first line. The decision to use NSAIDs or steroids ± colchicine is provider dependent. Prolonged anti-inflammatory therapy may be necessary and escalation versus de-escalation should be guided by symptoms, inflammatory markers, and possibly cardiac MRI. For patients with symptoms refractory to anti-inflammatory medications, pericardiectomy is recommended. Note in effusive-constrictive pericarditis, there tends to be extensive involvement of the visceral pericardium, which requires epicardiectomy, and may need a specialized center.  

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References

1. Adler, Y., Charron, P., Imazio, M., Badano, L., Barón-Esquivias, G., Bogaert, J., Brucato, A., Gueret, P., Klingel, K., Lionis, C., Maisch, B., Mayosi, B., Pavie, A., Ristić, A. D., Sabaté Tenas, M., Seferovic, P., Swedberg, K., Tomkowski, W., Group, E. S. D., … Nesukay, E. (2015). 2015 ESC Guidelines for the diagnosis and management of pericardial diseasesThe 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, 36(42), 2921–2964. 
2. Ang, K. P., Nordin, R. B., Lee, S. C. Y., Lee, C. Y., & Lu, H. T. (2019). Diagnostic value of electrocardiogram in cardiac tamponade. The Medical Journal of Malaysia, 74(1), 51–56. 
3. Ariyarajah, V., & Spodick, D. H. (2007). Cardiac Tamponade Revisited. Texas Heart Institute Journal, 34(3), 347–351. 
4. Ayan, M., Siraj, A., & Bhatti, S. (2018). Effusive Constrictive Pericarditis. Journal of the American College of Cardiology, 71(11 Supplement), A2383. 
5. BECK, C. S. (1935). TWO CARDIAC COMPRESSION TRIADS. Journal of the American Medical Association, 104(9), 714–716. 
6. Chiabrando, J. G., Bonaventura, A., Vecchié, A., Wohlford, G. F., Mauro, A. G., Jordan, J. H., Grizzard, J. D., Montecucco, F., Berrocal, D. H., Brucato, A., Imazio, M., & Abbate, A. (2020). Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review. Journal of the American College of Cardiology, 75(1), 76–92. 
7. Effusive-Constrictive Pericarditis: Maybe Not as Rare and as Bad as We Thought. (n.d.). American College of Cardiology. Retrieved October 13, 2020, from https://www.acc.org/latest-in-cardiology/articles/2019/04/08/10/42/effusive-constrictive-pericarditis
8. Fowler, N. O. (1993). Cardiac tamponade. A clinical or an echocardiographic diagnosis? Circulation, 87(5), 1738–1741. 
9. Guntheroth, W. G. (2007). Sensitivity and specificity of echocardiographic evidence of tamponade: Implications for ventricular interdependence and pulsus paradoxus. Pediatric Cardiology, 28(5), 358–362. 
10. Jesper K., Poulsen, Steen Hvitfeldt, & Mølgaard, Henning. (n.d.). Cardiac tamponade: A clinical challenge. Retrieved October 13, 2020, from https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Cardiac-tamponade-a-clinical-challenge
11. Kearns, M. J., & Walley, K. R. (2018). Tamponade: Hemodynamic and Echocardiographic Diagnosis. Chest, 153(5), 1266–1275. 
12. Klein, A. L., Abbara, S., Agler, D. A., Appleton, C. P., Asher, C. R., Hoit, B., Hung, J., Garcia, M. J., Kronzon, I., Oh, J. K., Rodriguez, E. R., Schaff, H. V., Schoenhagen, P., Tan, C. D., & White, R. D. (2013). American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: Endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. Journal of the American Society of Echocardiography: Official Publication of the American Society of Echocardiography, 26(9), 965-1012.e15. https://doi.org/10.1016/j.echo.2013.06.023 
13. Little William C., & Freeman Gregory L. (2006). Pericardial Disease. Circulation, 113(12), 1622–1632. 
14. McGee, S. R. (2018). Evidence-based physical diagnosis (4th edition). Elsevier. 
15. Pérez-Casares, A., Cesar, S., Brunet-Garcia, L., & Sanchez-de-Toledo, J. (2017). Echocardiographic Evaluation of Pericardial Effusion and Cardiac Tamponade. Frontiers in Pediatrics, 5. 
16. Roy, C. L., Minor, M. A., Brookhart, M. A., & Choudhry, N. K. (2007). Does this patient with a pericardial effusion have cardiac tamponade? JAMA, 297(16), 1810–1818. 
17. Spodick, D. H. (2003). Acute cardiac tamponade. The New England Journal of Medicine, 349(7), 684–690. 
18. Stashko, E., & Meer, J. M. (2020). Cardiac Tamponade. In StatPearls. StatPearls Publishing. 
19. Swami, A., & Spodick, D. H. (2003). Pulsus paradoxus in cardiac tamponade: A pathophysiologic continuum. Clinical Cardiology, 26(5), 215–217. 

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CardioNerds Case Reports: Recruitment Edition Series Production Team

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