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The Rational Clinical Examination | Clinician's Corner

Does This Patient With a Pericardial Effusion Have Cardiac Tamponade?

Christopher L. Roy, MD; Melissa A. Minor, MD; M. Alan Brookhart, PhD; Niteesh K. Choudhry, MD, PhD
JAMA. 2007;297(16):1810-1818. doi:10.1001/jama.297.16.1810.
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Context Cardiac tamponade is a state of hemodynamic compromise resulting from cardiac compression by fluid trapped in the pericardial space. The clinical examination may assist in the decision to perform pericardiocentesis in patients with cardiac tamponade diagnosed by echocardiography.

Objective To systematically review the accuracy of the history, physical examination, and basic diagnostic tests for the diagnosis of cardiac tamponade.

Data Sources MEDLINE search of English-language articles published between 1966 and 2006, reference lists of these articles, and reference lists of relevant textbooks.

Study Selection We included articles that compared aspects of the clinical examination to a reference standard for the diagnosis of cardiac tamponade. We excluded studies with fewer than 15 patients. Of 787 studies identified by our search strategy, 8 were included in our final analysis.

Data Extraction Two authors independently reviewed articles for study results and quality. A third reviewer resolved disagreements.

Data Synthesis All studies evaluated patients with known tamponade or those referred for pericardiocentesis with known effusion. Five features occur in the majority of patients with tamponade: dyspnea (sensitivity range, 87%-89%), tachycardia (pooled sensitivity, 77%; 95% confidence interval [CI], 69%-85%), pulsus paradoxus (pooled sensitivity, 82%; 95% CI, 72%-92%), elevated jugular venous pressure (pooled sensitivity, 76%; 95% CI, 62%-90%), and cardiomegaly on chest radiograph (pooled sensitivity, 89%; 95% CI, 73%-100%). Based on 1 study, the presence of pulsus paradoxus greater than 10 mm Hg in a patient with a pericardial effusion increases the likelihood of tamponade (likelihood ratio, 3.3; 95% CI, 1.8-6.3), while a pulsus paradoxus of 10 mm Hg or less greatly lowers the likelihood (likelihood ratio, 0.03; 95% CI, 0.01-0.24).

Conclusions Among patients with cardiac tamponade, a minority will not have dyspnea, tachycardia, elevated jugular venous pressure, or cardiomegaly on chest radiograph. A pulsus paradoxus greater than 10 mm Hg among patients with a pericardial effusion helps distinguish those with cardiac tamponade from those without. Diagnostic certainty of the presence of tamponade requires additional testing.

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Figure 1. Relationship Between Intracardiac Filling Pressures and Intrapericardial Pressure and Cardiac Output in Cardiac Tamponade
Graphic Jump Location

As pericardial fluid volume increases to the limit of pericardial compliance, intrapericardial pressure rises. Cardiac output begins to fall as intrapericardial pressure equalizes with central venous, right atrial, and right ventricular end-diastolic pressures (right heart filling pressures), then rapidly falls as it equalizes with left atrial and left ventricular end-diastolic pressures (left heart filling pressures).

Figure 2. Echocardiogram of a 62-Year-Old Woman With Advanced Lung Cancer and Malignant Pericardial Effusion Causing Cardiac Tamponade
Graphic Jump Location

In this subcostal view captured in early ventricular diastole, a large, circumferential pericardial effusion measuring 3.3 cm in maximal diameter is compressing the heart, and the right ventricle is completely collapsed (see video at http://jama.com/cgi/content/full/297/16/1810/DC1).

Figure 3. Measurement and Mechanism of Pulsus Paradoxus
Graphic Jump Location

A, The examiner inflates the sphygmomanometer cuff fully, listens for Korotkoff sounds as the cuff is slowly deflated, and then notes the pressure at which Korotkoff sounds are initially audible only during expiration. As the cuff is further deflated, the examiner notes the pressure at which Korotkoff sounds become audible during expiration and inspiration. The difference between these 2 pressures is the pulsus paradoxus. In cardiac tamponade, the pulsus paradoxus measures greater than 10 mm Hg. Inspiratory diminution in the pulse wave amplitude seen on this arterial tracing demonstrates pulsus paradoxus. A similar phenomenon may be observed on a pulse oximeter waveform. B, During inspiration in the normal heart, negative intrapleural pressures increase venous return to the right ventricle and decrease pulmonary venous return to the left ventricle by increasing pulmonary reservoir for blood. As a result of increased right ventricular distention, the interventricular septum bows slightly to the left, and the distensibility, filling, and stroke volume of the left ventricle are mildly reduced. In expiration, these changes are reciprocal, resulting in the septum bowing to the right and a mild reduction in right ventricular filling. In the presence of cardiac tamponade, the reciprocal changes seen in the normal heart are exaggerated when the pericardial sac is filled with fluid, thus limiting distensibility of the entire heart. This results in a more dramatic reduction in filling of the left ventricle during inspiration, exacerbating the normal inspiratory decrease in stroke volume and blood pressure.




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