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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Physical Exam:

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

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.

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

Grading Pericardial Effusions ¹

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

Differential Diagnosis of Pericardial Effusion ^2-8

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 MH, Espinosa RE, Nishimura RA, et al. Pericardial Disease: Diagnosis and Management. Mayo Clinic Proceedings. 2010;85(6):572-593. doi:10.4065/mcp.2010.0046.
3. Lange, RA, Hillis, LD. Clinical practice. Acute pericarditis. The New England journal of medicine. 2004;351(21), 2195–2202. doi:10.1056/NEJMcp041997
4. Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J. 2013;34(16):1186-1197. doi:10.1093/eurheartj/ehs372.
5. LeWinter MM. Clinical practice. Acute pericarditis. N Engl J Med. 2014;371(25):2410-2416. doi:10.1056/NEJMcp1404070.
6. Vakamudi S, Ho N, Cremer PC. Pericardial Effusions: Causes, Diagnosis, and Management. Prog Cardiovasc Dis. 2017;59(4):380-388. doi:10.1016/j.pcad.2016.12.009.
7. Imazio M, Mayosi BM, Brucato A, et al. Triage and management of pericardial effusion. J Cardiovasc Med (Hagerstown). 2010;11(12):928-935. doi:10.2459/JCM.0b013e32833e5788.
8. Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004;25(7):587-610. doi:10.1016/j.ehj.2004.02.002.

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