cardiovascular-agents and Cardiac-Tamponade

The pericardium is composed of visceral and parietal components. In view of the pericardium's simple structure, pathologic processes involving it are understandably few. However, despite a limited number of clinical syndromes, the pericardium is affected by virtually every category of disease, including infectious, neoplastic, immune-inflammatory, metabolic, iatrogenic, and traumatic. Thus, the recognition of pericardial heart disease remains challenging. Treatment of pericardial disease is also problematic in that there is a paucity of randomized, placebo-controlled trials from which appropriate therapy may be selected and important clinical decisions assisted. This article reviews pericarditis and its sequelae, pericardial effusions, cardiac tamponade and constrictive pericarditis.

Topics: Cardiac Surgical Procedures; Cardiac Tamponade; Cardiovascular Agents; Evidence-Based Medicine; Humans; Pericardial Effusion; Pericardiectomy; Pericardiocentesis; Pericarditis; Pericarditis, Constrictive; Pericardium; Treatment Outcome

Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease which follows a relapsing and remitting course that can manifest in any organ system. While classic manifestations consist of arthralgia, myalgia, frank arthritis, a malar rash and renal failure to name a few, cardiac tamponade, however, is a far less common and far more dangerous presentation. We highlight the case of a 61year-old male with complaints of acute onset shortness of breath and generalized body aches associated with a fever and chills in the ER. A bedside echocardiogram revealed a significant pericardial effusion concerning for pericardial tamponade. An emergent pericardiocentesis performed drained 800mL of serosanguinous fluid. While denying a history of any rash, photosensitivity, oral ulcers, or seizures, his physical examination did reveal metacarpal phalangeal joint swelling along with noted pulsus paradoxus of 15-200mmHg. Subsequent lab work revealed ANA titer of 1:630 and anti-DS DNA antibody level of 256IU/mL consistent with SLE. This case highlights cardiac tamponade as a rare but life-threatening presentation for SLE and raises the need to keep it in the differential when assessing patients presenting with pertinent exam findings.

Topics: Antihypertensive Agents; Cardiac Tamponade; Cardiovascular Agents; Chills; Diltiazem; Dyspnea; Echocardiography; Fever; Humans; Lupus Erythematosus, Systemic; Male; Metoprolol; Middle Aged; Pericardial Effusion; Pericardiocentesis; Treatment Outcome

Monoplane hemodynamic TEE (hTEE) monitoring (ImaCor(®) ClariTEE(®)) might be a useful alternative to continuously evaluate cardiovascular function and we aimed to investigate the feasibility and influence of hTEE monitoring on postoperative management in cardiac surgery patients. After IRB approval we reviewed the electronic data of cardiac surgery patients admitted to our intensive care between 01/01/2012 and 30/06/2013 in a case-controlled matched-pairs design. Patients were eligible for the study when they presented a sustained hemodynamic instability postoperatively with the clinical need of an extended hemodynamic monitoring: (a) hTEE (hTEE group, n = 18), or (b) transpulmonary thermodilution (control group, n = 18). hTEE was performed by ICU residents after receiving an approximately 6-h hTEE training session. For hTEE guided hemodynamic optimization an institutional algorithm was used. The hTEE probe was blindly inserted at the first attempt in all patients and image quality was at least judged to be adequate. The frequency of hemodynamic examinations was higher (ten complete hTEE examinations every 2.6 h) in contrast to the control group (one examination every 8 h). hTEE findings, including five unexpected right heart failure and one pericardial tamponade, led to a change of current therapy in 89% of patients. The cumulative dose of epinephrine was significantly reduced (p = 0.034) and levosimendan administration was significantly increased (p = 0.047) in the hTEE group. hTEE was non-inferior to the control group in guiding norepinephrine treatment (p = 0.038). hTEE monitoring performed by ICU residents was feasible and beneficially influenced the postoperative management of cardiac surgery patients.

Topics: Aged; Aged, 80 and over; Cardiac Surgical Procedures; Cardiac Tamponade; Cardiovascular Agents; Echocardiography, Doppler, Color; Echocardiography, Transesophageal; Education, Medical, Graduate; Equipment Design; Feasibility Studies; Female; Germany; Heart Failure; Hemodynamics; Humans; Intensive Care Units; Internship and Residency; Male; Middle Aged; Monitoring, Physiologic; Postoperative Care; Predictive Value of Tests; Retrospective Studies; Time Factors; Transducers; Treatment Outcome

The diagnosis and management of pericardial disease are very challenging for clinicians. The evidence base in this field is relatively scarce compared with other disease entities in cardiology. In this article, we outline a unified, stepwise pathway-based approach for the management of pericardial disease. We used the "CHASER" acronym to define the entry points into the pathway. These include chest pain, hypotension or arrest, shortness of breath, echocardiographic or other imaging finding of pericardial effusion, and right-predominant heart failure. We propose a score for the assessment of pericardial effusion that is composed of the following 3 parameters: the etiology of the effusion, the size of the effusion, and the echocardiographic assessment of hemodynamic parameters. The score is applied to clinically stable patients with pericardial effusion to quantify the necessity of pericardial effusion drainage. A stepwise, pathway-based approach to the management of pericardial disease is intended to provide guidance for clinicians in decision-making and a patient-tailored evidence-based approach to medical and surgical therapy for pericardial disease. The pathway for the management of pericardial disease is the ninth project to be incorporated into the "Advanced Cardiac Admission Program" at Saint Luke's Roosevelt Hospital Center of Columbia University in New York. Further studies should focus on the validation of the feasibility, efficacy, and reliability of this pathway.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Cardiac Tamponade; Cardiovascular Agents; Chest Pain; Clinical Protocols; Critical Pathways; Disease Management; Echocardiography; Electrocardiography; Evidence-Based Practice; Heart Failure; Hemodynamics; Humans; Hypotension; Pericardial Effusion; Pericardiocentesis; Pericardium; Program Evaluation; Severity of Illness Index

Few data exist on gender-related differences in clinical presentation, diagnostic findings, management, and outcomes in acute aortic dissection (AAD).. Accordingly, we evaluated 1078 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) to assess differences in clinical features, management, and in-hospital outcomes between men and women. Of the patients enrolled in IRAD (32.1%) with AAD, 346 were women. Although less frequently affected by AAD (32.1% of AAD), women were significantly older and had more often presented later than men (P=0.008); symptoms of coma/altered mental status were more common, whereas pulse deficit was less common. Diagnostic imaging suggestive of rupture, ie, periaortic hematoma, and pleural or pericardial effusion were more commonly observed in women. In-hospital complications of hypotension and tamponade occurred with greater frequency in women, resulting in higher in-hospital mortality compared with men. After adjustment for age and hypertension, women with aortic dissection die more frequently than men (OR, 1.4, P=0.04), predominantly in the 66- to 75-year age group. Moreover, surgical outcome was worse in women than men (P=0.013); type A dissection in women was associated with a higher surgical mortality of 32% versus 22% in men despite similar delay, surgical technique, and hemodynamics.. Our analysis provides insights into gender-related differences in AAD with regard to clinical characteristics, management, and outcomes; important diagnostic and therapeutic implications may help shed light on aortic dissection in women to improve their outcomes.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Aortic Aneurysm; Aortic Dissection; Cardiac Tamponade; Cardiovascular Agents; Case Management; Combined Modality Therapy; Consciousness Disorders; Europe; Female; Hospital Mortality; Humans; Hypotension; Life Tables; Male; Middle Aged; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Registries; Retrospective Studies; Risk Factors; Sex Factors; Survival Analysis; Treatment Outcome; United States