43F with a history of HTN and diastolic heart failure presenting with two days of shortness of breath. Reports that symptoms are worse at night when lying down to sleep and associated with a cough productive of white sputum. She also reports intermittent left-sided chest pain, described as sharp and exacerbated by cough or deep inspiration. She denies fevers/chills, nausea/vomiting, sick contacts or recent travel.
- Diabetes Mellitus (Type II)
- Diastolic heart failure
- Cesarean section
- Father with MI at 76 years-old
- Lives at home.
- Denies tobacco, alcohol or drug abuse.
- Lasix 40mg p.o. daily
- Lisinopril 20mg p.o. daily
- Atenolol 50mg p.o. daily
- Omeprazole 20mg p.o. daily
- Lantus 14 units daily
- Novolin 6 units t.i.d
|Gen:||Adult female in no acute distress, alert and responding appropriately to questions.|
|HEENT:||PERRL, EOMI, mucous membranes moist.|
|CV:||RRR, no murmurs appreciated, no JVD.|
|Lungs:||Crackles at right lung base.|
|Abd:||Soft, non-tender, non-distended, without rebound/guarding.|
|Ext:||1+ pitting edema in bilateral lower extremities to knee.|
|Neuro:||AAOx4, grossly normal peripheral sensation and motor strength.|
- Troponin: 0.15
- Procalcitonin: 0.15
- CBC: 10.9/9.1/26.4/296
- BMP: 134/4.6/104/22/56/2.87/214
Measured in the largest dimension, suggestive of a moderate to large pericardial effusion.
E-Point Septal Separation
E-Point Septal Separation (EPSS), estimated here is the smallest distance between the anterior leaflet of the mitral valve and intraventricular septum. Values > 12mm are suggestive of depressed ejection fraction.
Left Ventricular Hypertrophy
Thickened left ventricular wall.
Pericardial Effusion - Subxiphoid
Pericardial Effusion - Parasternal Long
Pericardial Effusion - Parasternal Short
- CXR: Consolidation involving the majority of the right lung, cardiomegaly.
- Bedside Echo: LVEF 55%, concentric LVH, no wall motion abnormality, moderate pericardial effusion noted, RV not collapsed.
43F with a history of HTN, diastolic heart failure presenting with SOB.
#SOB: CXR finding of right-sided consolidation with history of productive cough, evidence of leukocytosis with neutrophil predominance, and relative hypoxemia suggestive of community-acquired pneumonia. No evidence of systemic inflammatory response. PE unlikely, patient is not bed-bound and alternative diagnosis more likely.
– Start empiric antimicrobial therapy ceftriaxone 1g IV q24h, azithromycin 500mg IV q24h.
#Pericardial Effusion: Noted on bedside echo, no evidence of RV collapse to suggest cardiac tamponade. Also, no JVD and pulsus paradoxus measured at 8mmHg.
– Obtain formal transthoracic echocardiogram to evaluate effusion.
– Consult cardiology if worsening hemodynamics
#Elevated Troponin: No ECG changes suggestive of acute ST-elevation MI. May represent NSTEMI though historical features not consistent with ACS.
– Trend troponin/EKG q.8.h. x3
– Give aspirin 325mg, consider anti-coagulation.
– Consider stress echo prior to discharge
#Elevated Creatinine: Baseline unknown, likely acute component with or without chronic kidney disease.
– Volume resuscitation as tolerated, follow repeat chemistry.
#Hypertension: Asymptomatic, resume home medications.
Physiology of Cardiac Tamponade 1
- Intrapericardial pressure (IPP) normally reflects intrathoracic pressure (ITP).
- Inspiration: low ITP → low RAP → increased RA filling.
- Expiration: high ITP → low LAP → increased LA filling.
- Increased pericardial fluid → increased IPP → increased LA/RA filling pressures (diastolic dysfunction) → increased variation with respiration.
- Earliest hemodynamic change in cardiac tamponade is JVD or IVC dilation.
IVC variation as marker for RAP 1
|IVC Diameter (cm)||Change with Respiration (%)||RAP (mmHg)|
Grading Pericardial Effusions 1
|Grade||Echo-free space (mm)||Size (mL)|
Differential Diagnosis of Pericardial Effusion 2,3
History and Physical Exam in Patients with Acute Pericarditis 2,3
|Positional||No||Yes (worse when supine)||No|
|Duration||Minutes to hours||Hours to days||Hours to days|
|Improves with NG||Yes||No||No|
- Schairer, J. R., Biswas, S., Keteyian, S. J., & Ananthasubramaniam, K. (2011). A Systematic Approach to Evaluation of Pericardial Effusion and Cardiac Tamponade. Cardiology in Review, 19(5), 233–238. doi:10.1097/CRD.0b013e31821e202c
- Khandaker, M. H., Espinosa, R. E., Nishimura, R. A., Sinak, L. J., Hayes, S. N., Melduni, R. M., & Oh, J. K. (2010). Pericardial Disease: Diagnosis and Management. Mayo Clinic Proceedings, 85(6), 572–593. doi:10.4065/mcp.2010.0046
- Lange, R. A., & Hillis, L. D. (2004). Clinical practice. Acute pericarditis. The New England journal of medicine, 351(21), 2195–2202. doi:10.1056/NEJMcp041997