Subacute (medical) tamponade develops over a period of days or even weeks. Previous studies have shown that subacute tamponade is uncommonly associated with hypotension. On the contrary, many of those patients are indeed hypertensive at initial presentation. We sought to determine the prevalence and predictors of hypertensive cardiac tamponade and hemodynamic response to pericardial effusion drainage. We conducted a retrospective study of patients who underwent pericardial effusion drainage for subacute pericardial tamponade. Diagnosis of pericardial tamponade was established by the treating physician based on clinical data and supportive echocardiographic findings. Patients were defined as hypertensive if initial systolic blood pressure (BP) was ≥140 mm Hg. Thirty patients with subacute tamponade who underwent pericardial effusion drainage were included in the analysis. Eight patients (27%) were hypertensive with a mean systolic BP of 167 compared to 116 mm Hg in 22 nonhypertensive patients. Hypertensive patients with tamponade were more likely to have advanced renal disease (63% vs 14%, p <0.05) and pre-existing hypertension (88% vs 46, p <0.05) and less likely to have systemic malignancy (0 vs 41%, p <0.05). Systolic BP decreased significantly in patients with hypertensive tamponade after pericardial effusion drainage. Those results are consistent with previous studies with an estimated prevalence of hypertensive tamponade from 27% to 43%. In conclusion, a hypertensive response was observed in approximately 1/3 of patients with subacute pericardial tamponade. Relief of cardiac tamponade commonly resulted in a decrease in BP.
Cardiac tamponade is a potentially life-threatening disorder believed to be commonly associated with low blood pressure (BP) and even shock. However, many patients with subacute tamponade are indeed hypertensive at initial presentation. The goal of the present study was to determine the prevalence and predictors of hypertensive cardiac tamponade and hemodynamic response to pericardial effusion drainage.
Methods
We conducted a retrospective study of patients who underwent pericardial effusion drainage (percutaneous or surgical) for pericardial tamponade at St. Luke’s–Roosevelt Hospital Center (New York, New York) from April 2007 to December 2011. Diagnosis of pericardial tamponade was established by the treating physician based on suggestive clinical data (dyspnea, tachycardia, pulsus paradoxus, increased jugular venous pressure, and cardiomegaly on chest x-ray) and supportive echocardiographic findings. Patients with acute (surgical) tamponade during or immediately after a percutaneous procedure and after thoracotomy and chest trauma were excluded. Demographic, laboratory, and clinical data were obtained by retrospective chart review. Patients were defined as hypertensive if the initial systolic BP was ≥140 mm Hg. Echocardiograms were reviewed by 2 independent observers for the size and hemodynamic significance of the pericardial effusion and a consensus was obtained. Large effusion was defined as the largest pericardial fluid pocket measuring ≥2 cm. Supportive echocardiographic criteria included right atrial end-diastolic collapse and/or right ventricular early diastolic collapse. Additional echocardiographic signs for pericardial tamponade included inferior vena cava engorgement and respiratory variation in flow velocities across the mitral and tricuspid valves. Pericardial effusion scoring index was calculated as previously described.
Comparisons between groups were performed using nonparametric tests (Mann–Whitney test for continuous variables and Fisher’s exact tests for categorical variables). Analysis was performed using a standard statistical package (SPSS 16.0 for Windows, SPSS, Inc., Chicago, Illinois).
Results
From April 2007 to December 2011, 30 patients underwent pericardial effusion drainage for subacute pericardial tamponade and were included in the study. Eight patients (27%) were hypertensive with a mean systolic BP of 167 compared to 116 mm Hg in 22 nonhypertensive patients (p <0.01). Characteristics of patients in the 2 groups are presented in Table 1 . Dyspnea was the most common presenting complaint (77% of patients), which is similar to other studies. There was no significant age difference between groups (mean age 58 years in hypertensive patients vs 56 years in nonhypertensive patients, p = 0.74). Large effusion was present in 7 hypertensive patients (88%) and 15 nonhypertensive patients (68%, p = 0.29). Rates of right atrial collapse and right ventricular collapse were similar between hypertensive and nonhypertensive patients (88% vs 73%, p = 0.38; 63% vs 82%, p = 0.26, respectively). Hypertensive patients with tamponade were more likely to have advanced renal disease with a serum creatinine level >2.5 mg/dl (63% vs 14%, p <0.05) and pre-existing hypertension (88% vs 46%, p <0.05) and less likely to have systemic malignancy (0% vs 41%, p <0.05).
| Patient Number | Age (years)/Sex | Initial Heart Rate (beats/min) | Initial BP (mm Hg) | Pericardial Effusion Score | Fluid Drained (mL) | Cause of Effusion |
|---|---|---|---|---|---|---|
| Hypertensive | ||||||
| 1 | 34/M | 121 | 177/120 | 6 | 800 | Renal |
| 2 | 47/M | 110 | 156/96 | 4 | 250 | Pericarditis |
| 3 | 54/M | 112 | 150/101 | 6 | 500 | Renal |
| 4 | 59/M | 85 | 199/71 | 6 | 1,200 | Renal |
| 5 | 60/F | 110 | 182/92 | 6 | 250 | Heart failure |
| 6 | 65/M | 118 | 147/92 | 5 | 300 | Post-procedure |
| 7 | 70/F | 85 | 168/65 | 4 | 700 | Post-procedure |
| 8 | 72/F | 74 | 156/87 | 6 | 800 | Post-procedure |
| Nonhypertensive | ||||||
| 1 | 21/F | 105 | 119/85 | 7 | 800 | Malignant |
| 2 | 23/F | 96 | 126/100 | 3 | 800 | Hypothyroidism |
| 3 | 31/F | 123 | 115/62 | 7 | 450 | Renal |
| 4 | 42/F | 120 | 91/61 | 7 | 100 | Idiopathic |
| 5 | 43/F | 99 | 100/59 | 6 | 1,000 | Pericarditis |
| 6 | 47/F | 80 | 106/69 | 4 | 1,000 | Post-procedure |
| 7 | 49/M | 101 | 110/70 | 6 | 700 | Malignant |
| 8 | 51/F | 109 | 125/82 | 5 | 350 | Liver cirrhosis |
| 9 | 51/M | 128 | 120/83 | 6 | 800 | Idiopathic |
| 10 | 54/F | 146 | 135/88 | 4 | 200 | SLE |
| 11 | 57/M | 102 | 115/88 | 8 | 500 | Malignant |
| 12 | 58/M | 64 | 137/70 | 6 | 400 | Malignant |
| 13 | 59/F | 144 | 102/70 | 5 | 300 | Malignant |
| 14 | 63/F | 125 | 103/69 | 5 | 500 | Post-procedure |
| 15 | 65/F | 88 | 119/77 | 9 | 200 | Aortic dissection |
| 16 | 68/M | 97 | 139/79 | 7 | 700 | Malignant |
| 17 | 69/F | 93 | 121/56 | 6 | 800 | Post-pericardiotomy |
| 18 | 69/F | 116 | 100/55 | 7 | 300 | Malignant |
| 19 | 71/F | 128 | 106/72 | 7 | 400 | Malignant |
| 20 | 77/M | 96 | 138/88 | 7 | 850 | Pericarditis |
| 21 | 77/F | 146 | 107/80 | 7 | 600 | Malignant |
| 22 | 91/F | 76 | 115/65 | 7 | 400 | Idiopathic |
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