Woman With Abdominal Pain, Ascites, And Dyspnea

A 34-year-old woman presents to the emergency department (ED) with rapidly progressive dyspnea. The patient has a history of metastatic vaginal clear cell adenocarcinoma secondary to diethylstilbestrol( exposure in utero. Following her diagnosis in 1990, she was treated with surgery, chemotherapy, and radiation. She had done well for years until a recurrence of the cancer to the left lung was found last year. She completed a course of chemotherapy with doxorubicin( hydrochloride and cisplatin( 1 month ago. One week before the patient’s ED visit, acute right upper quadrant abdominal pain, ascites, and dyspnea developed. Before she arrived at the ED, she was profoundly dyspneic at rest and had experienced episodes of nearsyncope when standing. The patient has no history of cardiovascular illness, chest pain, dyspnea on exertion, orthopnea, peripheral edema, or abdominal distention. She has had no recent fevers, cough, or malaise. She previously had good exercise tolerance. She is not taking any medications. She does not smoke, drink alcohol(, or use illicit drugs. On examination, the patient is in acute distress; she is pale and tachypneic. Her blood pressure is 86 mm Hg by palpation; her heart rate is 130 beats per minute. A pulsus paradoxus is noted. Her respiration rate is 26 breaths per minute, and oxygen saturation is 93% on room air. When sitting upright, she has jugular venous distention to the level of the jaw. She has decreased breath sounds at the bases. Her heart sounds are distant and alternate in intensity. The liver is palpable 2 finger breadths below the costal margin and pulsatile. Her abdomen is distended and ascites is present. Her extremities are cool, and there is 1+ peripheral edema. Her ECG is shown. 1. What cardiac diagnosis best explains the clinical findings? 2. What abnormalities are evident on the patient’s ECG? 3. Which other management measures are recommended?1. What cardiac diagnosis best explains the clinical findings? This patient has pericardial tamponade. The clinical syndrome that develops when pericardial fluid interferes with diastolic filling is related to the rapidity of fluid accumulation, the quantity of fluid, and the distensibility of the pericardium. As little as 100 mL of rapidly accumulating fluid can produce tamponade, although a large quantity of fluid developing slowly may not interfere with cardiac function. The most common causes of pericardial tamponade in medical patients are infectious pericarditis (of viral, bacterial, mycobacterial, or fungal origin); malignant pericardial effusions; irradiation-induced injury; collagen( vascular disease; and uremia. Impaired diastolic ventricular filling reduces stroke volume. The heart rate increases to maintain cardiac output and a narrow pulse pressure subsequently occurs. As impairment of filling becomes more severe, hypotension and shock ensue. Increased rightsided pressures distend the jugular veins, and pulsus paradoxus can be elicited. Pulsus paradoxus is caused by more pronounced limitation of left ventricular filling during inspiration because of the left ventricle’s interaction with the right ventricle. Among the most common early symptoms of pericardial tamponade are dyspnea during exertion and fatigue. If tamponade develops gradually, peripheral edema and GI symptoms (including abdominal fullness resulting from hepatomegaly or ascites) may be noted. Late symptoms include dyspnea at rest, chest pain, dizziness, and syncope. 2. What abnormalities are evident on the patient’s ECG? The ECG shows sinus tachycardia at a rate of 122 beats per minute. In addition, “electrical alternans,” the beat-to-beat alternation in the amplitude of the QRS complex, is evident in all 12 leads (Figure). This ECG finding, characteristic of pericardial tamponade, is believed to be caused by periodic swinging of the heart within the fluid-filled pericardium. 3. Which other management measures are recommended? Further evaluation of patients with suspected pericardial tamponade should include urgent echocardiography, which can demonstrate a pericardial effusion as an echo-free space around the heart. Echocardiography can also show collapse of the right atrium and right ventricle during diastole. A pendular swinging motion of the heart is also seen. The diagnosis of pericardial tamponade is confirmed by catheterization of the right heart, which reveals equalization of diastolic pressures in all cardiac chambers. Pericardiocentesis is performed as an emergent therapeutic measure. In this patient, 750 mL of bloody fluid was drained, which resulted in relief of her symptoms and restoration of her blood pressure. After the procedure, an ECG showed resolution of both tachycardia and electrical alternans. Cytologic analysis of the pericardial fluid revealed malignant cells. Therapeutic options for the prevention of recurrent symptomatic pericardial effusions include intrapericardial sclerotherapy, subxiphoid pericardiotomy, and percutaneous balloon pericardiotomy.