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Adrian RJ, Alerhand S, Liteplo A, Shokoohi H. Is pulmonary hypertension protective against cardiac tamponade? A systematic review. Intern Emerg Med 2024:10.1007/s11739-024-03566-y. [PMID: 38622465 DOI: 10.1007/s11739-024-03566-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/14/2024] [Indexed: 04/17/2024]
Abstract
The presence of pulmonary hypertension (PH) may affect whether cardiac tamponade physiology develops from a pericardial effusion. Specifically, the increased intracardiac pressure and right ventricular hypertrophy associated with PH would seemingly increase the intrapericardial pressure threshold at which the right-sided chambers collapse. In this systematic review, we examined the impact of PH on the incidence, in-hospital and long-term mortality, and echocardiographic findings of patients with cardiac tamponade. Using the PRISMA guideline, a systematic search was conducted in PubMed, Academic Search Premier, Web of Science, Google Scholar, and the Cochrane Database for studies investigating PH and cardiac tamponade. The Newcastle-Ottawa Scale was used to analyze the quality of returned studies. Primary outcomes included the incidence of cardiac tamponade, as well as in-hospital and long-term mortality rates. Secondary outcomes were the presence or absence of echocardiographic findings of cardiac tamponade in patients with PH. Forty-three studies (9 cohort studies and 34 case reports) with 1054 patients were included. The incidence of cardiac tamponade was significantly higher in patients with PH compared to those without PH, 2.0% (95% CI 1.2-3.2%) vs. 0.05% (95% CI 0.05-0.05%), p < 0.0001, OR 40.76 (95% CI 24.8-66.9). The incidence of tamponade in patients with a known pericardial effusion was similar in those with and without PH, 20.3% (95% CI 12.0-32.3%) and 20.9% (95% CI 18.0-24.1%), p = 0.9267, OR 0.97 (95% CI 0.50-1.87). In patients with tamponade, those with PH demonstrated a significantly higher in-hospital mortality than those without PH, 38.8% (95% CI 26.4-52.8%) vs. 14.4% (95% CI 14.2-14.6%), p < 0.0001, OR 3.77 (95% CI 2.12-6.70). Long-term mortality in patients with tamponade was significantly lower in those with PH than in those without PH, 45.5% (95% CI 33.0-58.5%) vs. 59.1% (95% CI 54.7-63.4%), p = 0.0258, OR 0.576 (95% CI 0.33-1.01). However, after stratifying by non-malignant etiologies, the long-term mortality benefit for those with PH disappeared. In the studies that described specific echocardiographic findings of cardiac tamponade, only 10.5% of patients with PH and tamponade showed right atrial and right ventricular collapse. When evaluating patients with pericardial effusions, physicians must recognize the effects of underlying PH on the incidence, in-hospital and long-term mortality rates, and potentially atypical echocardiographic presentation of cardiac tamponade.
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Affiliation(s)
- Robert James Adrian
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 S. Orange Ave, Newark, NJ, 07103, USA
| | - Andrew Liteplo
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Hamid Shokoohi
- Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
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2
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Schaeffer WJ, Elegante M, Fung CM, Huang R, Theyyunni N, Tucker R. Variability in Interpretation of Echocardiographic Signs of Tamponade: A Survey of Emergency Physician Sonographers. J Emerg Med 2024; 66:e346-e353. [PMID: 38281857 DOI: 10.1016/j.jemermed.2023.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Cardiac tamponade is associated with high mortality, and making the diagnosis is a core skill of emergency physicians. Proper diagnosis relies on specific clinical and echocardiographic findings. It is not known whether expert sonographers consistently recognize echocardiographic signs of tamponade. OBJECTIVES To assess whether expert sonographers agree on echocardiographic signs of tamponade. METHODS A 20-question survey consisting of 18 cine loops and 2 still images was distributed to the Academy of Emergency Ultrasound Section of the Society for Academic Emergency Medicine. Respondents answered "yes" or "no" to whether there was echocardiographic evidence of tamponade. Subgroup analyses of demographics and echocardiographic views were reported. The data were analyzed using Krippendorff's alpha (α) to assess interrater reliability (IRR) between respondents. RESULTS Eighty-four physicians responded and 56 completed the survey. All partial and completed surveys were analyzed. The overall IRR was poor (α = 0.60, 95% confidence interval [CI] 0.44-0.76). Residency graduation within 5 years (α = 0.66, 95% CI 0.5-0.8) was associated with higher IRR compared with those > 5 years (α = 0.53, 95% CI 0.37-0.69). The highest IRR was observed when images of mitral valve inflow pulse-wave Doppler (α = 0.81, CI 0.70-0.92) were used and the poorest IRR was on images from the parasternal short view (α = 0.28, 95% CI 0.05-0.49). CONCLUSION There was poor agreement among expert emergency medicine sonographers in identifying echocardiographic signs of cardiac tamponade from a single cine loop or clip without clinical context. Further investigation is warranted to understand differences in recognition of clinical tamponade.
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Affiliation(s)
- William J Schaeffer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Marco Elegante
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Christopher M Fung
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Robert Huang
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Nik Theyyunni
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ryan Tucker
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
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Adler Y, Ristić AD, Imazio M, Brucato A, Pankuweit S, Burazor I, Seferović PM, Oh JK. Cardiac tamponade. Nat Rev Dis Primers 2023; 9:36. [PMID: 37474539 DOI: 10.1038/s41572-023-00446-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/22/2023]
Abstract
Cardiac tamponade is a medical emergency caused by the progressive accumulation of pericardial fluid (effusion), blood, pus or air in the pericardium, compressing the heart chambers and leading to haemodynamic compromise, circulatory shock, cardiac arrest and death. Pericardial diseases of any aetiology as well as complications of interventional and surgical procedures or chest trauma can cause cardiac tamponade. Tamponade can be precipitated in patients with pericardial effusion by dehydration or exposure to certain medications, particularly vasodilators or intravenous diuretics. Key clinical findings in patients with cardiac tamponade are hypotension, increased jugular venous pressure and distant heart sounds (Beck triad). Dyspnoea can progress to orthopnoea (with no rales on lung auscultation) accompanied by weakness, fatigue, tachycardia and oliguria. In tamponade caused by acute pericarditis, the patient can experience fever and typical chest pain increasing on inspiration and radiating to the trapezius ridge. Generally, cardiac tamponade is a clinical diagnosis that can be confirmed using various imaging modalities, principally echocardiography. Cardiac tamponade is preferably resolved by echocardiography-guided pericardiocentesis. In patients who have recently undergone cardiac surgery and in those with neoplastic infiltration, effusive-constrictive pericarditis, or loculated effusions, fluoroscopic guidance can increase the feasibility and safety of the procedure. Surgical management is indicated in patients with aortic dissection, chest trauma, bleeding or purulent infection that cannot be controlled percutaneously. After pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be considered to prevent recurrence and effusive-constrictive pericarditis.
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Affiliation(s)
- Yehuda Adler
- Sackler Faculty of Medicine, Tel Aviv University, Bnei Brak, Israel.
- College of Law and Business, Ramat Gan, Israel.
| | - Arsen D Ristić
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
| | - Massimo Imazio
- Cardiothoracic Department, Cardiology, University Hospital Santa Maria della Misericordia, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, Fatebenefratelli Hospital, The University of Milan, Milan, Italy
| | - Sabine Pankuweit
- Department of Internal Medicine-Cardiology, Philipps University Marburg, Marburg, Germany
| | - Ivana Burazor
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Institute for Cardiovascular Diseases "Dedinje" and Belgrade University, Faculty of Medicine, Belgrade, Serbia
| | - Petar M Seferović
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Bothwell KD, Ling FS, Ambrosini R, Baran TM, Lorca MC, Chaturvedi A. Standardized Criteria for Identification of Cardiac Tamponade on Non-Electrocardiogram-gated Computed Tomography: Correlation With Echocardiographic Findings. J Thorac Imaging 2023; 38:W44-W51. [PMID: 36546839 DOI: 10.1097/rti.0000000000000688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE To identify imaging parameters that can help in the diagnosis of cardiac tamponade on non-electrocardiogram (ECG)-gated computed tomography (CT) of the chest. MATERIALS AND METHODS Retrospective analysis of 64 patients who had undergone CT and echocardiography for evaluation of cardiac tamponade. Of 64 patients, 34 were diagnosed with tamponade and underwent pericardiocentesis for further diagnosis and treatment. CT measurements obtained were: pericardial effusion (PeEff) pocket size in 6 locations (anterior, posterior, superior, inferior, right, and left lateral), pericardial thickening, diameters of the coronary sinus, upper superior vena cava, lower superior vena cava, and inferior vena cava. In addition, cardiac chamber sizes were measured. Subjective assessment of coronary sinus compression, pericardial enhancement, and pericardial thickening were also recorded. RESULTS Measurement of the sum of the right lateral and left lateral PeEff thickness resulted in 91.2% sensitivity and 86.7% specificity for cardiac tamponade with a threshold of 30 mm (receiver-operating characteristic area under the curve=0.94 [0.84 to 0.98], P <0.0001). Using the combination of inferior PeEff >16 mm, sum of right lateral and left lateral PeEff>30 mm, and presence of pericardial thickening resulted in 56% sensitivity and 100% specificity and positive predictive value for the determination of cardiac tamponade. CONCLUSIONS Our study suggests that CT measurements related to PeEff size and thickness aid in the diagnosis of cardiac tamponade.
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Affiliation(s)
| | - Frederick S Ling
- Medicine, Cardiology, University of Rochester Medical Center, Rochester, NY
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Sullivan A, Dennis ASC, Rathod K, Jones D, Rosmini S, Manisty C, Bhattacharyya S, Foggo V, Conibear J, Koh T, Rees P, Ozkor M, Thornton CC, O'Mahony C. Pericardial Fluid Analysis in Diagnosis and Prognosis of Patients Who Underwent Pericardiocentesis. Am J Cardiol 2023; 198:79-87. [PMID: 37210977 DOI: 10.1016/j.amjcard.2023.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 03/16/2023] [Accepted: 04/18/2023] [Indexed: 05/23/2023]
Abstract
In this study, we aimed to examine the diagnostic yield of pericardial fluid biochemistry and cytology and their prognostic significance in patients with percutaneously drained pericardial effusions, with and without malignancy. This is a single-center, retrospective study of patients who underwent pericardiocentesis between 2010 and 2020. Data were extracted from electronic patient records, including procedural information, underlying diagnosis, and laboratory results. Patients were grouped into those with and without underlying malignancy. A Cox proportional hazards model was used to analyze the association of variables with mortality. The study included 179 patients; 50% had an underlying malignancy. There were no significant differences in pericardial fluid protein and lactate dehydrogenase between the 2 groups. Diagnostic yield from pericardial fluid analysis was greater in the malignant group (32% vs 11%, p = 0.002); 72% of newly diagnosed malignancies had positive fluid cytology. The 1-year survival was 86% and 33% in nonmalignant and malignant groups, respectively (p <0.001). Of 17 patients who died within the nonmalignant group, idiopathic effusions were the largest group (n = 6). In malignancy, lower pericardial fluid protein and higher serum C-reactive protein were associated with increased risk of mortality. In conclusion, pericardial fluid biochemistry has limited value in determining the etiology of pericardial effusions; fluid cytology is the most important diagnostic test. Mortality in malignant pericardial effusions may be associated with lower pericardial fluid protein levels and a higher serum C-reactive protein. Nonmalignant pericardial effusions do not have a benign prognosis and close follow-up is required.
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Affiliation(s)
- Andrew Sullivan
- Department of Interventional Cardiology, St Bartholomew's Hospital, London, United Kingdom.
| | - Adam S C Dennis
- Department of Interventional Cardiology, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Krishnaraj Rathod
- Department of Interventional Cardiology, St Bartholomew's Hospital, London, United Kingdom
| | - Daniel Jones
- Department of Interventional Cardiology, St Bartholomew's Hospital, London, United Kingdom
| | - Stefania Rosmini
- King's College Hospital NHS Trust Foundation, London, United Kingdom
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Department of Cardiac Imaging, St Bartholomew's Hospital, London, United Kingdom
| | | | - Vanessa Foggo
- Department of Haematology, St Bartholomew's Hospital, London, United Kingdom
| | - John Conibear
- Department of Oncology, St Bartholomew's Hospital, London, United Kingdom
| | - Tat Koh
- Department of Interventional Cardiology, St Bartholomew's Hospital, London, United Kingdom
| | - Paul Rees
- Department of Interventional Cardiology, St Bartholomew's Hospital, London, United Kingdom
| | - Mick Ozkor
- Department of Interventional Cardiology, St Bartholomew's Hospital, London, United Kingdom
| | | | - Constantinos O'Mahony
- Department of Interventional Cardiology, St Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
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Song D, Shabani J, Jaiswal V, Paudel K, Gupta A, Rubinstein D. Anagrelide-induced pericardial effusion in a patient with essential thrombocythemia. Clin Case Rep 2023; 11:e7246. [PMID: 37102091 PMCID: PMC10123307 DOI: 10.1002/ccr3.7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/29/2023] [Accepted: 04/07/2023] [Indexed: 04/28/2023] Open
Abstract
Pericardial effusion leading to cardiac tamponade can occur due to a multitude of etiologies, one of which is medication adverse effects. In patients with comorbid conditions, this can prove to be a challenge in its co-management along with the primary disease. We present a rare case of anagrelide-induced pericardial effusion that is presented with tamponade physiology in a patient with essential thrombocythemia. After cautiously weighing the risks and benefits of further invasive interventions following an unsuccessful pericardiocentesis, the decision was to stop anagrelide while managing the pericardial effusion medically. Therefore, managing pericardial effusion should be tailored to each patient individually through shared decision-making.
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Affiliation(s)
- David Song
- Department of Internal MedicineIcahn School of Medicine at Mount Sinai – Elmhurst Hospital CenterNew York CityNew YorkUSA
| | - Jawad Shabani
- Department of Internal MedicineIcahn School of Medicine at Mount Sinai – Elmhurst Hospital CenterNew York CityNew YorkUSA
| | - Vikash Jaiswal
- Department of Cardiovascular ResearchLarkin Community HospitalMiamiFloridaUSA
| | - Kusum Paudel
- Kathmandu University school of medical sciencesDhulikhelNepal
| | - Arjun Gupta
- Department of Cardiovascular MedicineIcahn School of Medicine at Mount Sinai – Elmhurst Hospital CenterNew York CityNew YorkUSA
| | - David Rubinstein
- Department of Cardiovascular MedicineIcahn School of Medicine at Mount Sinai – Elmhurst Hospital CenterNew York CityNew YorkUSA
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Alerhand S, Adrian RJ, Long B, Avila J. Pericardial tamponade: A comprehensive emergency medicine and echocardiography review. Am J Emerg Med 2022; 58:159-174. [DOI: 10.1016/j.ajem.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/03/2022] [Indexed: 10/18/2022] Open
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Way A, Ozdemir S, Berges B, Getman N, Liang X, Mendenhall NP, Collins G, Cutter D, Mailhot Vega RB. Pericardial Effusion during Proton Therapy in a Patient with Chemorefractory Hodgkin Lymphoma. Int J Part Ther 2021; 8:76-81. [PMID: 35530189 PMCID: PMC9009456 DOI: 10.14338/ijpt-21-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/16/2021] [Indexed: 11/21/2022] Open
Abstract
We present a case of recurrent pericardial effusion presenting during proton therapy in a 24-year-old female receiving mediastinal treatment for classical Hodgkin lymphoma. Pericardial effusion is typically considered an event accompanying lymphoma diagnosis or as a subacute or late effect of radiotherapy. Rarely has it been described as occurring during radiation treatment with photon-based radiotherapy, let alone proton therapy. It is unclear what underlying cause triggered recurrent effusion in this patient. Identifying and managing pericardial effusion during treatment delivery is important to consider as it may affect radiation dosimetry, particularly with proton therapy. Doing so will help ensure patients receive optimal treatment and minimize the risks of morbidity and mortality.
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Affiliation(s)
- Ashley Way
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Savas Ozdemir
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Barbara Berges
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nataliya Getman
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Xiaoying Liang
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Graham Collins
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Cutter
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Raymond B. Mailhot Vega
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
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Intra-arrest transoesophageal echocardiographic findings and resuscitation outcomes. Resuscitation 2020; 154:31-37. [DOI: 10.1016/j.resuscitation.2020.06.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/19/2020] [Accepted: 06/29/2020] [Indexed: 01/08/2023]
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