Suspected tamponade: Classic workup remains important but isn't evidence-based

April 25, 2007

Boston, MA - Pulsus paradoxus is no longer a paradox, but it may be among the most reliable of the traditional clinical signs suggesting cardiac tamponade "when faced with a patient with pericardial effusion and the echo is equivocal," observed Dr Christopher L Roy (Brigham and Women's Hospital, Boston, MA).

The lead author of an analysis that explores the evidence base for the classic history, clinical examination, and lab workup in such cases, which appears in the April 25, 2007 issue of the Journal of the American Medical Association [1], Roy told heartwire that there's little out there. On the other hand, he said, what evidence there is points to a decent level of sensitivity, if not specificity, for several of the traditional signs.

"Based on our review of the literature, dyspnea, tachycardia, elevated jugular venous pressure, pulsus paradoxus, or cardiomegaly on chest radiograph is seen in 70% or more of patients with a known pericardial effusion and cardiac tamponade," Roy et al write. One study suggests that "a pulsus paradoxus greater than 10 mm Hg increases the likelihood of cardiac tamponade, while a pulsus paradoxus of 10 mm Hg or less decreases the likelihood." Moreover, they write, "the presence and degree of pulsus paradoxus may be helpful to predict the degree of hemodynamic compromise" in such patients with suspected tamponade.

The analysis can be viewed as "codifying the clinical gestalt," according to Roy, such that "in an absence of those findings, you might be able to avoid an echo in some patients." But that's a leap, he said, because all of the studies in the analysis included patients with echo-identified pericardial effusion.

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