Lau, CP

Pang, FC

Wan, SH

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Title ECG Round: A lady with dyspnoea for 2 daysAuthor(s) Pang, FC; Wan, SH; Lau, CPCitation Hong Kong Practitioner, 1999, v. 21 n. 9, p. 435-437Issued Date 1999URL http://hdl.handle.net/10722/45082Rights Creative Commons: Attribution 3.0 Hong Kong LicenseECG ROUNDA Lady With Dyspnoea For 2 DaysClinical History:A 48-year-old lady with known history of carcinoma of cervix stage IIIb, presented with dyspnoea for 2 days.Her blood pressure was 90/50. The following ECG was obtained. (Figure 1)Figure 1I I IQuestion 1: What was the ECG diagnosis?A. Acute pulmonary embolismB. Pericardial tamponadeC. Atrial flutterD. Atrial ectopicThis ECG Round was prepared by: Dr. F C Pang, MBChB(CUHK), MRCP(UK)Dr. S H Wan, MBChB(CUHK). MRCP(UK.), FHKCP, FHKAMDepartment of Medicine & Geriatrics,Tuen Mun Hospital.Professor C P Lau, MD. FRCP, FRACP, FACPDepartment of Medicine,The University of Hong Kong.Address for correspondence: Dr. F C Pang, Department of Medicine & Geriatrics, Tuen Mun Hospital, New Territories.435ECG RoundECG ROUNDAnswer : B. Pericardial tamponadeThe ECG shows low voltage of QRS in all leads andsinus tachycardia with rate of 152/min. In the long leadII, the electrical alternans (marked with 40 was noted andPR segment depression (marked with ^ in lead I) wasalso seen in some complexes. Therefore, the diagnosisis likely to be pericardial effusion.An echocardiogram was performed for this patientand confirmed the diagnosis. The tamponade effect onthe heart can be shown by the fo l lowing features:abnormal respiratory changes in ventricular dimensions,right and left atrial compression, right and left ventriculardiastolic collapse, abnormal respiratory variation intricuspid and mitral flow velocities, dilated inferior venacava with lack of inspiratory collapse.1 Sometimes, aswinging heart can be seen and it is the proposed causeof electrical alternans on ECG.Clinical features include elevated jugular venouspressure, low blood pressure, Kussmau l sign andparadoxical pulse. CXR of this patient also revealedcardiomegaly with a globular heart.The three ECG signs (PR depression, electricalalternans, low voltage) were specific but not sensitive forpericardial effusion (specificity 89% to 100%; sensitivity,1 to 17%) and cardiac tamponade (specificity 86% to99%; sensit ivity, O to 42%). The low voltage wasassociated with large and moderate pericardial effusions.2Therefore the 12-lead ECG has poor diagnostic value forpericardial effusion and cardiac tamponade. The clinicalsymptoms and signs, CXR, ECG and then echocardiogramare necessary in making a correct diagnosis.Question 2: What is the most likely causeof the diagnosis?A. MalignancyB. MyocarditisC. Drug inducedD. Acute myocardial infarctionAnswer : A. MalignancyNeoplastic pericarditis most commonly results fromeither direct extension or lymphat ic metastasis of aprimary intra-thoracic tumour. It can also spread byhaematogenous metas tas is of a d is tant neoplasm.Carcinoma of the lung and breast can frequently spreadto the pe r i ca rd ium d i r e c t l y wh i l e l ymphoma andleukaemia spread via haematogenous route.Infective causes of pericardial effusion include acutevira l p e r i c a r d i t i s , TB p e r i c a r d i t i s , and p u r u l e n tpericarditis (most common in children).Aseptic pericarditis can result from acute myocardialinfarct ion, post-cardiac in jury syndrome and uraemicpericarditis.Question 3: What would you do?A. AnticoagulationB. PericardiocentesisC. ObservationD. Direct current cardioversionAnswer : B. PericardiocentesisThe decision of pericardiocentesis strongly dependson etiology and clinical status of the patient. Whenhaemodynamic compromise is severe with dyspnoea orfalling blood pressure, urgent pericardial drainage isindicated.There are a number of approaches for performingpericardiocentesis. Subxiphoid approach was preferredbecause the chances of lacerating a coronary vessel orentering the left pleural space are minimized.Figure 2 is the ECG done after pericardiocentesisand it shows sinus rhythm within heart rate of 100/min.For those effusions which are likely to recur, it is usefulto leave a plastic cannula or a drain in the pericardiumfor several days. Surgery like subxyphoid pericardiotomyunder local anaesthesia can be done together with biopsyof the pericardium for histological study.436Hong Kong Practitioner 21 (9) September 1999NDFigure 2For treatment of a malignant pericardial effusion, Referencesintroduction of sclerosing agents, creation of a pericardialwindow, complete pericardial stripping (pericardiectomy), 1. Noble O. Fowler: Cardiac tamponade. a clinical or an echocardiographic, . . , . . . , ' diagnosis? Circulation 1993;87(5):1738-1741.Cardiac irradiation or systemic chemotherapy can be 2 Mark J. Eisenberrg: The diagnosis of pericardial effusion and cardiac tam-considered. • ponadeby 12-lead ECG:CHEST 1996;110:318-324.C O R R I G E N D U M An Editorial error occurred in the Gastric Cancer - AnOverview by Dr. K.M. Chu, HK Pract 1999;20(8):357-364, Page 363, Figure 1b.The arrow should be pointing to a liver metastasis which has responded tochemotherapy.437

ECG Round: A lady with dyspnoea for 2 days

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ECG Round: A lady with dyspnoea for 2 days

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