Pericardial Effusion

HPI:

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.
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PMH:

  • Hypertension
  • Diabetes Mellitus (Type II)
  • Hyperlipidemia
  • Diastolic heart failure

PSH:

  • Cesarean section

FH:

  • Father with MI at 76 years-old

SHx:

  • Lives at home.
  • Denies tobacco, alcohol or drug abuse.

Meds:

  • 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

Allergies:

NKDA

Physical Exam:

VS: T 98.2 HR 81 RR 19 BP 219/91 O2 95% RA
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.

Labs/Studies:

  • Troponin: 0.15
  • Procalcitonin: 0.15
  • CBC: 10.9/9.1/26.4/296
  • BMP: 134/4.6/104/22/56/2.87/214

Imaging:

Pericardial Effusion

Pericardial Effusion

Measured in the largest dimension, suggestive of a moderate to large pericardial effusion.

E-Point Septal Separation

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

Left Ventricular Hypertrophy

Thickened left ventricular wall.

Pericardial Effusion - Subxiphoid

Pericardial Effusion - Subxiphoid

Pericardial Effusion - Parasternal Long

Pericardial Effusion - Parasternal Long

Pericardial Effusion - Parasternal Short

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.

Assessment/Plan:

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)
<2.1 >50% 0-5
<2.1 <50% 5-10
>2.1 >50% 5-10
>2.1 <50% >15

Grading Pericardial Effusions 1

Grade Echo-free space (mm) Size (mL)
Small <10 100
Moderate 10-20 100-500
Large >20 >500

Differential Diagnosis of Pericardial Effusion 2,3

Differential Diagnosis of Pericardial Effusion

History and Physical Exam in Patients with Acute Pericarditis 2,3

Symptom/Sign ACS Pericarditis PE
Quality Pressure Sharp Sharp
Pleuritic No Yes Yes
Positional No Yes (worse when supine) No
Duration Minutes to hours Hours to days Hours to days
Improves with NG Yes No No
Friction Rub No Yes No
S3 Maybe No No

References:

  1. 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
  2. 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
  3. 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