Case Presentation:
In our #AMReport at @WCHospital (or #WCHMorningReport), we discussed a case of cardiac tamponade in a patient presenting with new-onset exertional dyspnea and low voltage QRS complexes on ECG. Echocardiography revealed a large malignancy-related pericardial effusion and she required urgent pericardiocentesis.
Dyspnea Image-Based Approach:
Source: Jakubovic 2016
Review of the Wells PE Criteria:

- Use these criteria to determine PE probability
- Scores of <2 indicate low probability; D-dimer prior to additional imaging may be helpful at ruling out VTE in this setting
- Can also use the PERC Rule to determine who is very low risk
Approach to Elevated D-Dimer:
- For VTE: 80-85% sensitive, 93-100% negative predictive value
- Causes of elevated D-Dimer
- Arterial occlusion (MI, stroke, dissection)
- VTE (DVT, PE)
- Systemic disease (beware of false positives): Malignancy, sepsis or infection, pregnancy, trauma etc.
Approach to Low Voltage ECG:
Etiologies of Cardiac Tamponade:
- Acute tamponade: ventricular rupture (secondary to trauma, myocardial infarction or iatrogenic), aortic dissection
- Subacute tamponade:
- Infection: Viral (HIV), bacterial, TB, Fungal
- Malignancy: Particularly lung, breast, Hodgkin’s, mesothelioma
- Inflammatory: SLE, RA, dermatomyositis
- Post-MI
- Iatrogenic or post surgery/procedure
- Drugs: Hydralazine, procainamide, INH
- Renal failure (Uremia)
- Post-radiation
- Three most common causes of moderate-large pericardial effusions: idiopathic, iatrogenic, malignant
Features of Cardiac Tamponade:
Physical Exam
- As per the JAMA Rational Clinical Exam series:
- Pulsus paradoxus >12mmgHg: +LR 5.6, -LR 0.03
- >10 mmgHg 82% sensitive, + LR 3.3, -LR 0.03
- Cardiomegaly on CXR: 89% sensitive
- Low voltages on ECG: only 42% sensitive
- Pulsus paradoxus >12mmgHg: +LR 5.6, -LR 0.03
Echo Findings
- Echocardiographic signs suggestive of tamponade include:
- Pericardial effusion
- Disatolic RV (high specificity) or RA collapse
- IVC dilatation (“plethora”) with minimal respiratory variation (high sensitivity)
Source: Alerhand & Carter (2019)
Principles of Management of Tamponade:
- Hemodynamic effects warrant urgent intervention
- Temporize with IV fluids to help maintain RV patency
- Transfer to an intensive care setting and pericardiocentesis is the definitive management
- Identify & treat cause
Additional Reading:
- Roy, CL; Minor, MA; Brookhart, A; Choudhry, N. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA. 2007;297(16):1810-1818. doi:10.1001/jama.297.16.1810.
- Spodick DH. Acute cardiac tamponade. New England Journal of Medicine. 2003 Aug 14;349(7):684-90.