A 55-year-old man is brought to the emergency department due to shortness of breath and weakness. The symptoms have been present for approximately 3 weeks but have rapidly progressed over the last 2 days. He felt too weak to get up to use the bathroom today. The patient was diagnosed with non-small cell lung cancer 2 years ago. At that time, he underwent surgical resection, followed by cisplatin-based combination chemotherapy. Since then, he has had follow-up CT scans every 6 months without evidence of recurrence. His last scan was 5 months ago. Other medical history includes mitral valve prolapse, for which he has been followed with echocardiography every 3 years. The patient used to take antibiotics prior to dental procedures but stopped a few years ago when his cardiologist advised him that it was no longer necessary. He currently takes no medications. His mother died of congestive heart failure at age 80 and his father has emphysema. The patient does not use tobacco, alcohol, or illicit drugs. He formerly worked as a diesel mechanic but retired at the time of his cancer diagnosis. Temperature is 37.8 C (100 F), blood pressure is 85/60 mm Hg, and pulse is 110/min and regular. Cardiac auscultation reveals distant heart sounds. The lungs are clear to auscultation. He has 1+ pitting lower extremity edema bilaterally. Bedside echocardiography shows moderate pericardial effusion. Which of the following best confirms the need for immediate invasive management in this patient?
A)Early diastolic right ventricular collapse on echocardiography
B)Increase in height of jugular venous pulsation on expiration
C)Inspiratory fall of 8 mm Hg in the systolic blood pressure
D)Large v wave in the jugular venous pulsation
E)Low-voltage QRS complexes on ECG

Question

A 55-year-old man is brought to the emergency department due to shortness of breath and weakness.  The symptoms have been present for approximately 3 weeks but have rapidly progressed over the last 2 days.  He felt too weak to get up to use the bathroom today.  The patient was diagnosed with non-small cell lung cancer 2 years ago.  At that time, he underwent surgical resection, followed by cisplatin-based combination chemotherapy.  Since then, he has had follow-up CT scans every 6 months without evidence of recurrence.  His last scan was 5 months ago.  Other medical history includes mitral valve prolapse, for which he has been followed with echocardiography every 3 years.  The patient used to take antibiotics prior to dental procedures but stopped a few years ago when his cardiologist advised him that it was no longer necessary.  He currently takes no medications.  His mother died of congestive heart failure at age 80 and his father has emphysema.  The patient does not use tobacco, alcohol, or illicit drugs.  He formerly worked as a diesel mechanic but retired at the time of his cancer diagnosis.  Temperature is 37.8 C (100 F), blood pressure is 85/60 mm Hg, and pulse is 110/min and regular.  Cardiac auscultation reveals distant heart sounds.  The lungs are clear to auscultation.  He has 1+ pitting lower extremity edema bilaterally.  Bedside echocardiography shows moderate pericardial effusion.  Which of the following best confirms the need for immediate invasive management in this patient?
A)Early diastolic right ventricular collapse on echocardiography
B)Increase in height of jugular venous pulsation on expiration
C)Inspiratory fall of 8 mm Hg in the systolic blood pressure
D)Large v wave in the jugular venous pulsation
E)Low-voltage QRS complexes on ECG

Quizplus · Accepted Answer

Explanation: 11ec2b69_c112_11cb_8f63_a32ed0d38c60_MD0005_00 IVC = inferior vena cava; JVD= jugular venous distension; LV = left ventricular; SBP = systolic blood pressure. Cardiac tamponade results from increased hydrostatic pressure in the pericardial space, leading to impaired diastolic filling of the right side of the heart. This patient's moderate pericardial effusion, which raises concern for recurrent lung malignancy, has led to subacute cardiac tamponade. With subacute presentation, patients typically have progressive dyspnea, fatigue, elevated jugular venous pressure (JVP), and lower extremity edema. As the size of the pericardial effusion increases, hypotension and distant heart sounds can eventually develop. Echocardiography visualizes pericardial effusion and can be diagnostic of cardiac tamponade; the most specific findings of tamponade physiology are early diastolic collapse of the right ventricle and right atrium. Other consistent findings include exaggerated respiratory variation of cardiac and venous flow and plethora of the inferior vena cava with lack of inspiratory collapse. Treatment requires rapid removal of pericardial fluid, which can be performed with catheter pericardiocentesis or surgical pericardial window. (Choice B) JVP increase during expiration is normal, as is JVP decrease during inspiration (due to increased compliance of the right ventricle). By contrast, Kussmaul sign refers to an abnormal increase (or a lack of decrease) in JVP during inspiration. It is typically seen in patients with constrictive pericarditis or restrictive cardiomyopathy; however, in patients with cardiac tamponade, although JVP is often elevated, Kussmaul sign rarely occurs. (Choice C) Systemic blood pressure normally decreases slightly during inspiration. Pulsus paradoxus is an exaggerated drop in systolic blood pressure (>10 mm Hg) due to bowing of the right ventricle into the left ventricle during inspiration. It is an important finding in cardiac tamponade. However, the finding is nonspecific as it can also occur in patients with severe asthma or chronic obstructive pulmonary disease, constrictive pericarditis, and marked obesity. (Choice D) A large v wave in jugular venous pulsation is seen in patients with severe tricuspid regurgitation. Patients with cardiac tamponade have an elevated JVP with an absent or a blunted y descent. jugular venous pulsation (Choice E) Low-voltage QRS complexes are seen on ECG in patients with moderate or large pericardial effusion. However, this finding is nonspecific as it can also be seen with conditions such as obesity, severe chronic obstructive pulmonary disease, and amyloidosis. When electrical alternans is present on ECG, it is relatively specific for tamponade. Educational objective: Subacute cardiac tamponade is characterized by progressive dyspnea, fatigue, jugular venous distension, and lower extremity edema. Echocardiography showing early diastolic collapse of the right ventricle and right atrium is the most specific diagnostic finding for tamponade physiology. References: Echocardiographic evaluation of pericardial effusion and cardiac tamponade. (http://www.ncbi.nlm.nih.gov/pubmed/28484689)

A 55-Year-Old Man Is Brought to the Emergency Department Due