eMedicine Specialties > Cardiology > Pericardial Disease

Cardiac Tamponade: Differential Diagnoses & Workup

Author: Chakri Yarlagadda, MD, FACC, FASNC, Consulting Cardiologist, St Elizabeth Hospital, Youngstown, OH
Contributor Information and Disclosures

Updated: Oct 30, 2008

Differential Diagnoses

Cardiogenic Shock
Pericarditis, Constrictive
Pericarditis, Constrictive-Effusive
Pulmonary Embolism
Tension Pneumothorax

Other Problems to Be Considered

Large pleural effusion: Cases of cardiac tamponade have been reported with large pleural effusions. The increased intrapleural pressure resulting from large pleural effusions can be transmitted to the pericardial space and impair ventricular filling, thus simulating the hemodynamic equivalent of cardiac tamponade.

Tension pneumopericardium: The hemodynamic changes simulate acute cardiac tamponade. Clinically, distant heart sounds, bradycardia, and shifting tympany occur over the precordium and a characteristic murmur is heard, termed bruit de la roue de moulin. This is usually observed in infants with mechanical ventilation but is also observed after sternal bone marrow aspiration, penetrating chest wall injury, esophageal rupture, and bronchopericardial fistula.

Rapid and labored breathing: Large decreases in intrathoracic pressure with deep inspirations, often observed during respiratory failure, can accentuate the pulsus paradoxus, simulating pericardial tamponade.

Workup

Laboratory Studies

  • Creatine kinase and isoenzymes: Levels are elevated in patients with myocardial infarction and cardiac trauma.
  • Renal profile and CBC count with differential: These tests are useful in the diagnosis of uremia and certain infectious diseases associated with pericarditis.
  • Coagulation panel: The prothrombin time and activated partial thromboplastin time are useful for determining bleeding risk during interventions, such as pericardial drainage, the placement of pericardial windows, or both.
  • Antinuclear antibody assay, erythrocyte sedimentation rate, and rheumatoid factor: Although nonspecific, results from these tests may give clues to a connective tissue disease predisposing to the development of pericardial effusion.
  • HIV testing: Approximately 24% of all pericardial effusions are reported to be associated with HIV infection.
  • Purified protein derivative testing: This is used to diagnose tuberculosis, which is an important and not uncommon cause of pericardial effusion and tamponade.

Imaging Studies

  • Chest radiography findings may show cardiomegaly, water bottle–shaped heart, pericardial calcifications, or evidence of chest wall trauma (see Media file 1).
  • Although echocardiography provides useful information, cardiac tamponade is a clinical diagnosis (see Clinical and Media file 3). The following may be observed with 2-dimensional echocardiography:
    • An echo-free space posterior and anterior to the left ventricle and behind the left atrium: After cardiac surgery, a localized posterior fluid collection without significant anterior effusion may occur and may readily compromise cardiac output.
    • Early diastolic collapse of the right ventricular free wall
    • Late diastolic compression/collapse of the right atrium
    • Swinging of the heart in its sac
    • LV pseudohypertrophy
    • A greater than 40% relative inspiratory augmentation of right-side flow
    • A greater than 25% relative decrease in inspiratory flow across the mitral valve
  • Conditions that may simulate pericardial effusion on 2-dimensional echocardiography include the following:
    • A large left pleural effusion
    • Any tumor surrounding the heart
    • Mitral annular calcification
    • A descending thoracic aorta
    • A catheter in the right ventricle
    • An enlarged left atrium
    • An annular subvalvular LV aneurysm
    • A bronchogenic cyst

Other Tests

  • With a 12-lead electrocardiogram (see Media file 2), the following findings are suggestive but not diagnostic of pericardial tamponade.
    • Sinus tachycardia
    • Low-voltage QRS complexes
    • Electrical alternans (also observed during supraventricular and ventricular tachycardia): Alternation of QRS complexes, usually in a 2:1 ratio, on electrocardiogram findings is called electrical alternans. This is due to movement of the heart in the pericardial space. Electrical alternans is also observed in patients with myocardial ischemia, acute pulmonary embolism, and tachyarrhythmias.
    • PR segment depression
  • Computed tomography (CT) imaging of the heart: Gold et al reported compression of the coronary sinus as observed by CT imaging as an earlier marker for cardiac tamponade in 46% of patients.4
  • Pulse-oximetry: Respiratory variability in pulse-oximetry waveform noted in patients with pulsus paradoxus. In a small group of patients with tamponade, Stone et al noted increased respiratory variability in pulse-oximetry waveform in all patients.5 This should raise the suspicion for hemodynamic compromise.

Procedures

Swan-Ganz catheterization

  • Before or after insertion of the Swan-Ganz catheter, the system must be zeroed after positioning the transducer at the midpoint of the left atrium. Then calibrate the monitoring system. Prior to insertion, test the balloon and flush all the ports. Then insert the catheter into one of the major veins. At a depth of 20 cm, inflate the balloon and slowly advance the catheter, while continuously monitoring the pressure from the distal lumen. Always deflate the balloon before withdrawing the Swan-Ganz catheter. The waveforms help indicate the position of the catheter tip if fluoroscopy is not readily accessible. At approximately the 40- to 50-cm mark, the wedge pressure is usually recorded. Secure the catheter position, and obtain a chest radiograph to confirm the position.
  • In tamponade, near equalization (within 5 mm Hg) of the right atrial, right ventricular diastolic, pulmonary arterial diastolic, and pulmonary capillary wedge pressure (reflecting left atrial pressure) occurs. The right atrial pressure tracings display a prominent systolic x descent and abolished systolic y descent.
  • Boltwood et al described the diastolic equalization of pulmonary capillary and right atrial pressures as predominantly inspiratory, known as the inspiratory traction sign.6 This is due to inspiratory traction of the taut pericardium by the diaphragm.

Histologic Findings

Occasionally, a pericardial biopsy is performed when the etiology of the pericardial effusion that caused the tamponade is unclear. This is especially useful in cases of tuberculous pericardial effusions because cultures of the pericardial fluid in these cases rarely yield a positive result for mycobacteria. However, granulomas seen on pericardial biopsy specimens are often seen in patients with tuberculous pericarditis. In general, cytopathologic findings from pericardial fluid and histologic findings from pericardial biopsy specimens depend on the underlying pathology.

More on Cardiac Tamponade

Overview: Cardiac Tamponade
Differential Diagnoses & Workup: Cardiac Tamponade
Treatment & Medication: Cardiac Tamponade
Follow-up: Cardiac Tamponade
Multimedia: Cardiac Tamponade
References
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References

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  4. Gold MM, Spindola-Franco H, Jain VR, Spevack DM, Haramati LB. Coronary sinus compression: an early computed tomographic sign of cardiac tamponade. J Comput Assist Tomogr. Jan-Feb 2008;32(1):72-7. [Medline].

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Further Reading

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Keywords

cardiac tamponade, pericardial tamponade, reduced ventricular filling, effusive-constrictive pericarditis, constrictive pericarditis, hemodynamic compromise, malignant disease, pericarditis, pericardial effusion, accumulation of fluid in the pericardial space, postmyocardial infarction, free wall ventricular rupture, Dressler syndrome, systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis, radiation therapy, antireflux surgery, pneumopericardium

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Contributor Information and Disclosures

Author

Chakri Yarlagadda, MD, FACC, FASNC, Consulting Cardiologist, St Elizabeth Hospital, Youngstown, OH
Chakri Yarlagadda, MD, FACC, FASNC is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, American Society of Nuclear Cardiology, and Heart Rhythm Society
Disclosure: Nothing to disclose.

Medical Editor

Russell F Kelly, MD, Program Director, Assistant Professor, Department of Internal Medicine, Division of Cardiology, Cook County Hospital, Rush Medical College
Russell F Kelly, MD is a member of the following medical societies: American College of Cardiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Ronald J Oudiz, MD, Director of Pulmonary Hypertension, Associate Professor, Department of Medicine, Division of Cardiology, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA
Ronald J Oudiz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association
Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Encysive Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

George A Stouffer III, MD, Henry A Foscue Distinguished Professor of Medicine and Cardiology, Director of Interventional Cardiology, Cardiac Catheterization Laboratory, Chief of Clinical Cardiology, Division of Cardiology, University of North Carolina Medical Center
George A Stouffer III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
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