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Cardiac Tamponade: A Classic Presentation
Published on Cancer Network (http://www.cancernetwork.com)
Cardiac Tamponade: A Classic Presentation
June 01, 2006 | Lung Cancer [1]
By William Yaakob, MD [2] and Anh-vu Nguyen, MD [3]
A 43-year-old woman presents to the emergency department with fatigue, dyspnea, and
intermittent chest pain of 3 days’ duration. Her symptoms have worsened since she arose, and 2
hours ago palpitations developed. She describes the chest pain as a heavy pressure under her
sternum that does not radiate; she denies fever, nausea, vomiting, and diaphoresis.
1. Dyspnea, chest pain, and palpitations
A 43-year-old woman presents to the emergency department with fatigue, dyspnea, and intermittent
chest pain of 3 days' duration. Her symptoms have worsened since she arose, and 2 hours ago
palpitations developed. She describes the chest pain as a heavy pressure under her sternum that
does not radiate; she denies fever, nausea, vomiting, and diaphoresis.
The patient has a history of rheumatic fever with mitral valve damage and congestive heart failure.
Three weeks earlier she underwent mitral valve replacement. Warfarin therapy was started, and last
week her prothrombin time was normal. Three days ago she complained of cough and congestion,
and an antibiotic was prescribed. She has no family history of coronary artery disease and does not
use alcohol or tobacco.
Temperature is 37oC (98.7oF); heart rate, 152 beats per minute; respiration rate, 22 breaths per
minute; blood pressure, 95/59 mm Hg; and oxygen saturation, 93% on room air. Breath sounds at
the base of both lungs are decreased; no wheezes or rhonchi. Heart sounds are faint, and rhythm is
irregularly irregular, without murmurs. There is marked jugular venous distention. Peripheral pulses
are weak and irregular; no edema in the extremities. No ecchymosis or bruising is evident.
White blood cell count is 18,000/μL; hemoglobin level, 9 g/dL; and hematocrit, 26.2%. An ECG shows
atrial fibrillation with a rapid ventricular response (158 beats per minute). Results of a basic
metabolic panel and digoxin and cardiac enzyme levels are all normal. INR is 5.9.
The patient is given intravenous diltiazem to control her ventricular rate, and an immediate cardiac
consultation is requested.
You order a supine radiograph of the chest. What clue on the film suggests the cause of the patient's
symptoms-- and what further steps will you take?
1. Dyspnea, chest pain, and palpitations: This patient exhibits the classic triad of symptoms of
cardiac tamponade: hypotension, muffled heart sounds, and distended neck veins. In addition, her
elevated INR strongly suggests hemorrhage into the pericardial sac.
The radiograph (A) reveals a massively enlarged cardiac silhouette. It is important to use the term
"cardiac silhouette" rather than "cardiomegaly" in this setting because the first term is broader and
encompasses pericardial effusion. The "water bottle" appearance of the cardiac silhouette here
indicates a pericardial effusion.
An echocardiogram (B) confirms the diagnosis; it clearly shows fluid within the pericardial sac
(arrow), which is consistent with a large pericardial effusion.
Pericardial effusions can be classified into 4 types based on their cause:
Transudative. These typically result from congestive failure, hypoalbuminemia, or radiation
therapy.
Hemorrhagic (as in this patient). Common causes are surgery, anticoagulants, trauma, and
neoplasm.
Lymphatic. These usually result from a neoplasm or congenital anomalies.
Fibrinous. Typical causes are infection, uremia, collagen vascular diseases, and
hypersensitivity.
A CT scan is ordered to better delineate the effusion and to assist in surgical planning. The axial
images (C, D) not only confirm the diagnosis, they also allow visualization of a safe pathway for
placement of a percutaneous drainage catheter (black lines).
A follow-up chest radiograph (E), obtained after drainage of approximately 1.5 liters of hemorrhagic
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Cardiac Tamponade: A Classic Presentation
Published on Cancer Network (http://www.cancernetwork.com)
fluid, shows a significant decrease in the size of the cardiac silhouette; the drainage catheter overlies
the right cardiac border.
Outcome of this case. The patient's coagulopathy was corrected, and the catheter was withdrawn.
Her symptoms markedly diminished, and she was discharged.
2. Syncope in a man with a history of lung cancer A 65-year-old man is brought to the
emergency department after he fainted an hour earlier. His wife reports that he was watching
television when his eyes rolled back and he shook and passed out. He regained consciousness after
30 seconds but was confused for about 5 minutes. During the past 2 weeks, he has felt weak and
has had several episodes of disorientation, nausea, and vomiting.
The patient has a history of small-cell carcinoma of the lung, for which he received radiation therapy
2 years ago. He was told after completion of therapy that the cancer was in remission. Although he
quit smoking 1 month ago, he has a 60 pack-year history of tobacco use. He denies any history of
seizures; hypertension; or heart, liver, or renal disease. There is no family history of seizures, cancer,
or heart problems. He denies chest pain, abdominal pain, diarrhea, and recent head trauma. The
patient's chronic dyspnea has recently worsened slightly, but he has not had hemoptysis.
He is in mild respiratory distress, secondary to pursed breathing. Temperature is 36.6oC (97.9oF);
heart rate, 88 beats per minute; respiration rate, 24 breaths per minute; blood pressure, 130/90 mm
Hg; and oxygen saturation, 91% on room air. You note decreased breath sounds and consolidation
on the left side. Heart sounds are regular, without murmurs. Abdomen and neck are normal. Stool is
heme-negative. A neurologic examination is normal.
A complete blood cell count reveals evidence of anemia: hemoglobin level is 10 g/dL and hematocrit,
31%. Sodium level is low (122 mEq/L), but levels of the remaining electrolytes are normal. Specific
gravity of the urine is concentrated (1.030), and PO2 is low (62 mm Hg on room air). A CT scan of the
head and an ECG reveal no abnormalities; cardiac enzyme levels are also normal.
You order a supine radiograph of the chest. What abnormality is evident, and how will you proceed
to nail down the diagnosis?
2. Syncope in a man with a history of lung cancer: The radiograph (A) reveals opacity of the
entire left hemithorax with a mediastinal shift to the left. The mediastinal shift is an important clue.
Masses and large effusions cause opacity, but they are associated with a mediastinal shift to the
contralateral side. An extensive atelectasis, on the other hand, results in a mediastinal shift to the
side with the opacity. Always include atelectasis in the differential diagnosis of an opaque
hemithorax—particularly if there is a mediastinal shift toward the affected side. Surgical removal of
the lung&mdwhich this patient has not undergone— has a similar radiographic appearance.
You order a CT scan to better delineate the pathology. The CT images (B, C) demonstrate collapse of
the left lung and a large effusion (right arrows). However, the degree of lung collapse is far more
severe than the effect of the pleural effusion, as demonstrated by the mediastinal shift to the left.
Close inspection of the lung windows reveals marked narrowing of the left main stem bronchus
(central arrows); this is likely the result of tumor recurrence, which would also account for the
dramatic atelectasis of the left lung. In older patients, a primary malignancy is a common cause of
obstruction. When obstruction occurs in such patients, a diligent search for endobronchial lesions is
indicated. These can often be identified on CT, particularly with the use of a faster, multislice
scanner and/or coronal and off-axis oblique images. If no lesions are evident on CT, bronchoscopy,
which is a more sensitive technique, may be helpful.
Outcome of this case. The patient was admitted with the diagnosis of new-onset seizure
secondary to hyponatremia, which was presumed to have resulted from the syndrome of
inappropriate secretion of antidiuretic hormone (SIADH), caused by recurrence of his small-cell
carcinoma. The diagnosis was supported by further testing, which demonstrated a high urine
osmolality (2000 mOsm/kg), a high urinary sodium concentration (22 mEq/L), and an elevated serum
concentration of antidiuretic hormone. The SIADH was corrected with fluid restriction and increased
oral sodium intake, measures were taken to improve pulmonary toilet, and the patient's oncologist
was consulted for treatment of his lung cancer.
Source URL: http://www.cancernetwork.com/cardiac-tamponade-classic-presentation
Links:
[1] http://www.cancernetwork.com/lung-cancer
[2] http://www.cancernetwork.com/authors/william-yaakob-md
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Cardiac Tamponade: A Classic Presentation
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[3] http://www.cancernetwork.com/authors/anh-vu-nguyen-md
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