Article

Consideration of atrial arrhythmias associated with cardiac tamponade and pericarditis

Atrial arrhythmiasassoc”>338 Correspondence / American Journal of Emergency Medicine 36 (2018) 319338

[5] Kitamura T, Kiyohara K, Sakai T, Iwami T, Nishiyama C, Kajino K, et al. Epidemiology and outcome of adult out-of-hospital cardiac arrest of non-Cardiac origin in Osaka: a population-based study. BMJ Open 2014;4:e006462.

Consideration of atrial arrhythmias

associated with cardiac tamponade and pericarditis?

To the Editor,

Pericarditis is a fairly common manifestation of systemic lupus ery- thematosus (SLE), but cardiac tamponade only occurs in about 3% of cases [1]. Such cases are uncommon but are increasingly reported, in- cluding as the presenting feature of SLE, with a recent report in this jour- nal of a 61-year old male which we read with great interest [2]. In this letter, we wish to briefly discuss a few features of this case report.

In this case the patient presented with clinical signs of tamponade and

was found to be in atrial flutter. In discussing this, the authors stated that the classic findings on electrocardiography include low voltage and elec- trical alternans but that atrial flutter had not been described before as a manifestation of tamponade [2]. In practice, we have seen patients in tamponade present with a variety of atrial arrhythmias. A review of the literature confirms that this is an established phenomenon. In a case describing Pericardial tamponade and atrial fibrillation in a patient with pericarditis, Krisanda reports atrial arrhythmia that resolved once pericardiocentesis was performed [3]. Reports of atrial flutter in tamponade and pericarditis from a variety of etiologies continue to be de- scribed [4,5]. Atrial arrhythmia in the presence of cardiac tamponade, with subsequent resolution of arrhythmia post-pericardiocentesis, has therefore been established as an expected presentation. Interestingly, in one study of 242 post-cardiac surgery patients, rhythm change from sinus to supraventricular tachycardia was a forerunner of significant peri- cardial effusion or tamponade [6].

Delving deeper, while this patient presented in tamponade it should be remembered that the Underlying etiology was pericarditis, from SLE. Outside of the well-known ST and PR segment changes, the question of ar- rhythmias in pericarditis was highly debated in the 20th century. Address- ing this, Spodick examined patients with acute pericarditis and showed that these patients can developed supraventricular arrhythmias, including atrial fibrillation and flutter [7,8]. More recently, Imazio et al. studied 822 cases of acute pericarditis and confirmed this occurrence [9]. In these stud- ies, incidence ranged from 4 to 7%. Therefore, atrial arrhythmias including atrial fibrillation and flutter are known to correlate with pericarditis and significant pericardial effusion which can cause tamponade.

Another point to consider is the authors’ assertion that pericardial tamponade was the initial presentation of SLE. While SLE can in fact pres- ent as a pericardial or pleural effusion, musculoskeletal manifestations are one of the most common presentation, specifically involving the small joints of the hands and wrist. The authors report that the patient experi- enced intermittent tenderness of the small joints of the hands and wrist for 1-2 years prior to presentation, which would identify this clinical symptom as the initial manifestation of SLE for the patient at hand.

We found the chest radiograph presented very interesting as it dem- onstrated increased cardiothoracic silhouette with a left-sided pleural ef- fusion. This co-existing pleuritis with a polyserositis picture has featured in many recent cases of tamponade in adult and childhood SLE. As we have previously suggested, with or without autoimmune serositis there appears to be a strong link between pericardial disease and pleural effu- sion especially left-sided effusions [10]. This association can be important

? Comment on: Li W, Frohwein T, Ong K. Cardiac tamponade as an initial presentation for systemic lupus erythematosus. Am J Emerg Med. 2017 Apr 29. pii:S0735-6757(17)30362-5.

as a clinical marker and as it can influence intrathoracic pressures and hemodynamics.

Last but not least, the diagnosis of cardiac tamponade was highly likely given the clinical findings this patient had, with hypotension, tachycardia, muffled heart sounds, distended neck veins, Pulsus paradoxus, and the findings on electrocardiogram and chest radiograph. In this case the next step chosen was computed tomography (CT) scanning. After CT, echocardiography was done which confirmed tamponade physiology. In an excellent article, Argullian et al. discuss several misconceptions about tamponade one of which is “Pericardial tamponade is a clinical diagnosis” [11]. They discuss the limited sensitivity of clinical findings. However, in this case the presence of so many clinical findings on history and physical exam could argue for a clinical diagnosis. Nevertheless, the point we wish to raise is that imaging with CT is not necessary for evaluation of pericar- dial effusion if echocardiography is available. Particularly in cases where tamponade is suggested, performing imaging with CT is recommended only in certain scenarios, and the patient must be hemodynamically stable [12].

Satish Maharaj, MBBS* Julio, Perez-Downes, DO Karan, Seegobin, MBBS

Department of Internal Medicine, University of Florida College of Medicine,

Jacksonville, FL, United States

*Corresponding author at: University of Florida College of Medicine, 653 W 8th St., LRC 4th Floor L-18, Jacksonville, Florida 32209, United States. E-mail address: [email protected] (S. Maharaj)

Simone, Chang, MBBS

Jackson Memorial Hospital, Miami, FL, United States

16 July 2017

https://doi.org/10.1016/j.ajem.2017.07.077

References

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    Imazio M, Lazaros G, Picardi E, Vasileiou P, Orlando F, Carraro M, et al. Incidence and prognostic significance of new onset atrial fibrillation/flutter in acute pericarditis. Heart Sep 2015;101(18):1463-7.

  8. Maharaj SS, Chang SM. Cardiac tamponade as the initial presentation of systemic lupus erythematosus: a case report and review of the literature. Pediatr Rheumatol Online J Mar 17 2015;13:9.
  9. Argulian E, Messerli F. Misconceptions and facts about pericardial effusion and tamponade. Am J Med 2013 Oct;126(10):858-61.
  10. Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imag- ing of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr Sep 2013;26(9):965-1012.e15.

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