Pericardial tamponade and coexisting pulmonary embolism as first manifestation of non-advanced lung adenocarcinoma

Is pulmonary hypertension protective against cardiac tamponade? A systematic review

The presence of pulmonary hypertension (PH) may affect whether cardiac tamponade physiology develops from a pericardial effusion. Specifically, the increased intracardiac pressure and right ventricular hypertrophy associated with PH would seemingly increase the intrapericardial pressure threshold at which the right-sided chambers collapse. In this systematic review, we examined the impact of PH on the incidence, in-hospital and long-term mortality, and echocardiographic findings of patients with cardiac tamponade. Using the PRISMA guideline, a systematic search was conducted in PubMed, Academic Search Premier, Web of Science, Google Scholar, and the Cochrane Database for studies investigating PH and cardiac tamponade. The Newcastle-Ottawa Scale was used to analyze the quality of returned studies. Primary outcomes included the incidence of cardiac tamponade, as well as in-hospital and long-term mortality rates. Secondary outcomes were the presence or absence of echocardiographic findings of cardiac tamponade in patients with PH. Forty-three studies (9 cohort studies and 34 case reports) with 1054 patients were included. The incidence of cardiac tamponade was significantly higher in patients with PH compared to those without PH, 2.0% (95% CI 1.2-3.2%) vs. 0.05% (95% CI 0.05-0.05%), p < 0.0001, OR 40.76 (95% CI 24.8-66.9). The incidence of tamponade in patients with a known pericardial effusion was similar in those with and without PH, 20.3% (95% CI 12.0-32.3%) and 20.9% (95% CI 18.0-24.1%), p = 0.9267, OR 0.97 (95% CI 0.50-1.87). In patients with tamponade, those with PH demonstrated a significantly higher in-hospital mortality than those without PH, 38.8% (95% CI 26.4-52.8%) vs. 14.4% (95% CI 14.2-14.6%), p < 0.0001, OR 3.77 (95% CI 2.12-6.70). Long-term mortality in patients with tamponade was significantly lower in those with PH than in those without PH, 45.5% (95% CI 33.0-58.5%) vs. 59.1% (95% CI 54.7-63.4%), p = 0.0258, OR 0.576 (95% CI 0.33-1.01). However, after stratifying by non-malignant etiologies, the long-term mortality benefit for those with PH disappeared. In the studies that described specific echocardiographic findings of cardiac tamponade, only 10.5% of patients with PH and tamponade showed right atrial and right ventricular collapse. When evaluating patients with pericardial effusions, physicians must recognize the effects of underlying PH on the incidence, in-hospital and long-term mortality rates, and potentially atypical echocardiographic presentation of cardiac tamponade.

Defying Occam's Razor: A Case of Pulmonary Embolism Masked By Cardiac Tamponade

BACKGROUND

Occam's razor instructs physicians to assume one single cause for multiple symptoms, whereas Hickam's dictum encourages them to suspect multiple concurrent pathologies. Although the general practice is to follow Occam's razor, occasionally Hickam's dictum reigns supreme. Here we present one such case, where the concurrent presence of two life-threatening pathologies posed clinical challenges in diagnosis and management.

CASE REPORT

Although cardiac tamponade and pulmonary embolism (PE) are known complications of malignancy, their concomitant existence is rare. Here we report a patient who presented with shortness of breath found to have both cardiac tamponade and submassive PE. Although the cardiac tamponade was initially diagnosed in the Emergency Department by bedside ultrasound and treated with pericardiocentesis, only a few hours later, when she deteriorated, the submassive PE was diagnosed, which was treated with heparin infusion and subsequently transitioned to a newer oral anticoagulant. The patient was later diagnosed as having primary breast cancer and metastatic lung adenocarcinoma. Why Should an Emergency Physician Be Aware of This? This raised unique diagnostic challenges, as both cardiac tamponade and PE present with obstructive shock. The increased right heart pressure from the PE could have paradoxically protected the patient from the tamponade effects of the pericardial effusion. Furthermore, the presence of cardiac tamponade may also mask the typical echocardiographic features of PE. The concurrent presence of two pathologies raised challenges and dilemmas in management. This case shows that physicians should maintain a high degree of suspicion of two pathologies when the patient deteriorates after the first pathology has been appropriately treated.

Cardiac tamponade: Better prognosis in association with pulmonary embolism: Case report

The tamponade leads to an increase in intrapericardial pressure, which impairs the diastolic filling of the ventricles and reduces ejection. However, the association with pulmonary arterial hypertension, which in turn leads to an intracardiac hyper-pressure, constitutes a compensatory mechanism. We report the case of a 23 year old patient followed for anemia due to martial deficiency for 2 years, who consulted us with right heart failure evolving for 5 months, a hemoptoic cough and chest tightness. The entire workup revealed a pericardial and pleural tamponade of tuberculous origin associated with a pulmonary embolism evaluated at 15% according to the Qanadli score. After stabilization of her hemodynamic state, the patient was put on anti-bacillary and anticoagulant treatment with a good improvement of her cardiopulmonary state. She was discharged after 1 month (satisfactory check-up), regularly followed up in outpatient clinic with check-up of hemostasis and cardiac echography every 2 weeks. She was declared cured of her tuberculosis after 6 months of treatment. There was no recurrence after two years of follow-up. The combination of tamponade and pulmonary hypertension is synergistic in that it improves the patient's prognosis.

Concurrent presentation of a hemorrhagic pericardial effusion and venous thromboembolism in malignancy: a systematic review of case studies

The concurrent presentation of symptomatic malignant pericardial hemorrhage and venous thromboembolism is a rare event that poses a clinical dilemma. Existing VTE guidelines do not indicate when, or if, anticoagulation therapy should be started after the treatment of the pericardial bleed. We performed a systematic review to compile the published clinical evidence on the occurrence of coexisting pericardial hemorrhage and VTE in cancer patients and to describe the clinical presentations and bleeding and thrombosis outcomes before and after anticoagulation therapy. We studied published case reports on patients with cancer who presented to the hospital with pericardial hemorrhage and VTE through April 11, 2019. We found seven published case reports. All patients had suffered from a pulmonary embolism and had pericardiocentesis during hospitalization. Five patients (71%) had lung cancer. Four patients (57%) were started on anticoagulation after pericardial drainage and survived the index event. Two patients (29%) were not started on anticoagulation after pericardiocentesis; only one of these patients survived the hospitalization. Pericardial bleeding risk in cancer may be inherent to malignancy, and it is unclear if anticoagulation use increases the risk of recurrent pericardial bleeding. The management of pericardial bleeding typically requires pericardiocentesis, and clinical registries, prospective collaboration projects, and case adjudication are needed to establish the safety of initiation of antithrombotic therapy in such patients.