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Cardiac tamponade differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Priyamvada Singh, M.D. [2]Ramyar Ghandriz MD[3]

Overview

The initial diagnosis of cardiac tamponade can be challenging, as there are a number of differential diagnoses, including tension pneumothorax, hypovolemia and acute congestive heart failure. The differential diagnosis of cardiac tamponade differs based on the type of cardiac tamponade (either acute or subacute).

Differentiating Cardiac Tamponade from Other Diseases

Differential Diagnosis of Acute Cardiac Tamponade

In a trauma patient presenting with PEA (pulseless electrical activity) in the absence of hypovolemia and tension pneumothorax, the most likely diagnosis is cardiac tamponade.[1] Other acute disorders that cardiac tamponade must be distinguished from include:

Differential Diagnosis of Subacute Cardiac Tamponade

Signs of classical cardiac tamponade include three signs, known as Beck’s triad. Hypotension occurs because of decreased stroke volume, jugular-venous distension due to impaired venous return to the heart, and muffled heart sounds due to fluid inside the pericardium.[2]

Other signs of tamponade include pulsus paradoxus (a drop of at least 10mmHg in arterial blood pressure on inspiration), and ST segment changes on the electrocardiogram, which may also show low voltage QRS complexes, as well as general signs & symptoms of shock (such as tachycardia, breathlessness and decreasing level of consciousness).

Echocardiography, which is the diagnostic test of choice, often demonstrates an enlarged pericardium or collapsed ventricles. Tamponade can often be diagnosed radiographically, if time allows and the chest x-ray may show a large, globular heart if the pericardial effusion is large.

Differential table

Classification of shock based on hemodynamic parameters. (CO, cardiac output; CVP; central venous pressure; PAD, pulmonary artery diastolic pressure; PAS, pulmonary artery systolic pressure; RVD, right ventricular diastolic pressure; RVS, right ventricular systolic pressure; SVO2, systemic venous oxygen saturation; SVR, systemic vascular resistance.)[3][4]
Type of Shock Etiology CO SVR PCWP CVP SVO2 RVS RVD PAS PAD
Cardiogenic Acute Ventricular Septal Defect ↓↓ ↑ N β€” ↑ ↑↑ ↑ β€” ↑↑ N β€” ↑ ↑ N β€” ↑ N β€” ↑
Acute Mitral Regurgitation ↓↓ ↑ ↑↑ ↑ β€” ↑↑ ↓ ↑ N β€” ↑ ↑ ↑
Myocardial Dysfunction ↓↓ ↑ ↑↑ ↑↑ ↓ N β€” ↑ N β€” ↑ N β€” ↑ ↑
Right Ventricular Infarction ↓↓ ↑ N β€” ↓ ↑↑ ↓ ↓ β€” ↑ ↑ ↓ β€” ↑ ↓ β€” ↑
Obstructive Pulmonary Embolism ↓↓ ↑ N β€” ↓ ↑↑ ↓ ↓ β€” ↑ ↑ ↓ β€” ↑ ↓ β€” ↑
Cardiac Tamponade ↓ β€” ↓↓ ↑ ↑↑ ↑↑ ↓ N β€” ↑ ↑ N β€” ↑ N β€” ↑
Distributive Septic Shock N β€” ↑↑ ↓ β€” ↓↓ N β€” ↓ N β€” ↓ ↑ β€” ↑↑ N β€” ↓ N β€” ↓ ↓ ↓
Anaphylactic Shock N β€” ↑↑ ↓ β€” ↓↓ N β€” ↓ N β€” ↓ ↑ β€” ↑↑ N β€” ↓ N β€” ↓ ↓ ↓
Hypovolemic Volume Depletion ↓↓ ↑ ↓↓ ↓↓ ↓ N β€” ↓ N β€” ↓ ↓ ↓
  • Note that that in Obstructive shock PCWP (left atrial pressure) which is an indicator of left circulation preload , decreases, but in tamponade it increases paradoxically due to pericardial effusion pressure on left atrium.



The following table outlines the major differential diagnoses of Shock on the basis of clinical manifestations..[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40]

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell); Coronary CT angiography (CCTA); multidetector row scanners (MDCT); Cardiovascular magnetic resonanceΒ β€”Β CMRI; Myocardial perfusion imaging (MPI); single-photon emission CT (SPECT); Positron emission tomography (PET) scanning; Magnetic resonance (MR) angiography, Computed tomographic (CT) angiography, and Transesophageal echocardiography (TEE), late gadolinium enhancement (LGE); right ventricular hypertrophy (RVH), right atrial enlargement (RAE), functional tricuspid regurgitation (TR), Pulmonary artery systolic pressure (PASP; adenosine deaminase (ADA); Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL2R); High-resolution CT (HRCT) scanning

Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Pericardial Tamponade[41][42] Acute or subacute May last for hours to days +/- + + – EKG findings:
Myocardial Infarction[5][6][7][8] Acute Commonly > 20 minutes – – + –
  • ST elevation MI (STEMI)
  • Non-ST elevation MI (NSTEMI) or Non Q wave
  • CCTA combined with MPI
Cardiac
Aortic Dissection[43][44] Sudden severe progressive pain (common) or chronic (rare) Variable
  • Tearing, ripping sensation, knife like
 – – + –
  • Nonspecific ST and T wave changes
Aortic intramural hematoma Sudden severe progressive pain (common) or chronic (rare) Variable
  • Tearing, ripping sensation, knife like
 – – + –
  • Nonspecific ST and T wave changes
Penetrating atherosclerotic aortic ulcer[45][46][47] Sudden severe pain Variable
  • Tearing, ripping sensation, knife like
 – – + –

_

_

Myocarditis[48][49][50] Acute or subacute Variable +/- + + –
Hypertrophic cardiomyopathy[51][52][53] Acute or subacute Variable Typical or atypical chest pain – – + – Non-specific

Echocardiography:

Genetic testing for HCM
Stress (takotsubo)

Cardiomyopathy[54][55][56][57]

Acute Commonly > 20 minutes – – + –
  • Setting of physical or emotional stress or critical illness
 Stress
Aortic Stenosis[58][59][60] Acute, recurrent episodes of angina 2-10 minutes – – + –
Heart Failure[61][62][63] Subacute or chronic Variable
  • Dull
  • Left sided chest pain
 + +/- + + Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Pulmonary Pulmonary Embolism[64][65] Acute May last minutes to hours + +/- + – Β Hormone replacement therapy

Cancer Oral contraceptive pills StrokeΒ  Pregnancy PostpartumΒ  Prior history ofΒ VTE ThrombophiliaΒ 

Spontaneous Pneumothorax[66][67] Acute May last minutes to hours – – + –
  • Rightward shift in the mean electrical axis
  • Loss of precordial R waves
  • Diminution of the QRS voltage
  • Precordial T wave inversions
  • CXR: White visceral pleural line on the chest radiograph
  • CT: small amounts of intrapleural gas, atypical collections of pleural gas, and loculated pneumothoraces
  • CT scan
Tension Pneumothorax[68][69] Acute May last minutes to hours – – + –
  • Trauma
  • Significant elevation of the ST-T segment from leads V1Β to V4
Pleural Effusion[70][71][72] Acute or subacute or chronic Variable + +/- + +/-
  • Typically not indicated
Acute chest syndrome (Sickle cell anemia)[73][74][75] Acute May last minutes to hours
  • Chest tightness
 + +/- + –
  • EKG typically not indicated
 —
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Gastrointestinal Perforated Peptic Ulcer[76][77][78] Acute +/- – – +/-
  • Not any auscultatory findings associated with this disease
  • Enamel erosion or other dental manifestations
Esophagitis[79][80][81] Acute Variable + + – +/-
  • No auscultatory finding
Esophageal Perforation[10] Acute Minutes to hours
  • Burning
  • Upper abdominal
 – +/- + –
    • Confirmed by water-soluble contrast esophagram
Mediastinitis[82][83][84][85] Acute, Chronic Variable
  • Retrosternal irritation
 +/- + + –
  • Nonspecific
  • Infection
  • Esophageal perforation
  • Post operative complication
  • Positive organisms in sternal culture
  • Leukocytosis
  • Positive blood cultures
  • Diffuse ST elevation
  • CT: Localize the infection and extent of spread
  • MRI: Assesses vascular involvement and complications
 CT scan
Pancreatitis[86][87][88][89][90] Acute, Chronic Variable – + + +/-
  • Alcohol abuse
  • Smoking
  • Genetic predisposition
  • Β Tachypnea
  • Hypoxemia
  • Hypotension
  • Cullen’s sign
  • Grey Turner signΒ 
  • ↑Amylase levels
  • ↑Lipase levelsΒ 
  • ↑ALT
  • ↑ALP
  • Leukocytosis
  • T-wave inversion
  • ST-segment depression
  • Β ST-segment elevationΒ rarely
  • Q-waves
  • CT: focal or diffuse enlargement of the pancreas
  • MRI: Pancreatic enlargement
  • CT Scan
IBD[91] Acute, Chronic Variable
  • Painful bowl movments
  • Bloody diarrhea
  • pus or mucus in the stool
  • Fistula
  • sepsis
  • pseudo memberanous colitis
 – + + +
  • Gastric perforation
  • Colon cancer
  • Genetic predisposition
  • Alcohol abuse
  • Smoking
  • Microbiata and infections
  • Hypotension
  • Abdominal tendernessΒ 
  • Electrolyte disturbance
  • Leukocytosis
  • T-wave inversion
  • ST-segment depression
  • Β ST-segment elevationΒ rarely
  • Q-waves
  • CT: Gastrointestinal inflamation
  • CT Scan
  • Colonoscopy
  • biopsy

References

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