Does this patient with a pericardial effusion have cardiac tamponade?
BACKGROUND
Cardiac tamponade is a state of hemodynamic compromise resulting from cardiac compression by fluid trapped in the pericardial space. The clinical examination may assist in the decision to perform pericardiocentesis in patients with cardiac tamponade diagnosed by echocardiography.


OBJECTIVE
To systematically review the accuracy of the history, physical examination, and basic diagnostic tests for the diagnosis of cardiac tamponade.


METHODS
MEDLINE search of English-language articles published between 1966 and 2006, reference lists of these articles, and reference lists of relevant textbooks.


METHODS
We included articles that compared aspects of the clinical examination to a reference standard for the diagnosis of cardiac tamponade. We excluded studies with fewer than 15 patients. Of 787 studies identified by our search strategy, 8 were included in our final analysis.


METHODS
Two authors independently reviewed articles for study results and quality. A third reviewer resolved disagreements.


RESULTS
All studies evaluated patients with known tamponade or those referred for pericardiocentesis with known effusion. Five features occur in the majority of patients with tamponade: dyspnea (sensitivity range, 87%-89%), tachycardia (pooled sensitivity, 77%; 95% confidence interval [CI], 69%-85%), pulsus paradoxus (pooled sensitivity, 82%; 95% CI, 72%-92%), elevated jugular venous pressure (pooled sensitivity, 76%; 95% CI, 62%-90%), and cardiomegaly on chest radiograph (pooled sensitivity, 89%; 95% CI, 73%-100%). Based on 1 study, the presence of pulsus paradoxus greater than 10 mm Hg in a patient with a pericardial effusion increases the likelihood of tamponade (likelihood ratio, 3.3; 95% CI, 1.8-6.3), while a pulsus paradoxus of 10 mm Hg or less greatly lowers the likelihood (likelihood ratio, 0.03; 95% CI, 0.01-0.24).


CONCLUSIONS
Among patients with cardiac tamponade, a minority will not have dyspnea, tachycardia, elevated jugular venous pressure, or cardiomegaly on chest radiograph. A pulsus paradoxus greater than 10 mm Hg among patients with a pericardial effusion helps distinguish those with cardiac tamponade from those without. Diagnostic certainty of the presence of tamponade requires additional testing.
Roy
Christopher L
CL
Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass 02115, USA. croy@partners.org
Minor
Melissa A
MA
Brookhart
M Alan
MA
Choudhry
Niteesh K
NK
D002305:Cardiac Tamponade / Q000175:diagnosis* / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy; D004452:Echocardiography; D006801:Humans; D010490:Pericardial Effusion / Q000150:complications* / Q000175:diagnosis / Q000628:therapy; D020519:Pericardiocentesis; D010808:Physical Examination; D011674:Pulse; D011859:Radiography