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False positive stress-test in a patient with pericardial effusion
International Journal of Cardiology 137 (2009) e33 – e34 www.elsevier.com/locate/ijcard
Letter to the Editor
False positive stress-test in a patient with pericardial effusion Candice Mateja, Joseph Mishkin, Malika George, Hemant Chheda, Maya Guglin ⁎ University of South Florida, FL, United States Tampa General Hospital, Tampa, FL, United States Received 16 March 2008; accepted 29 May 2008 Available online 3 September 2008
Abstract We report a case of false positive stress test in a patient with cardiac tamponade. After the drainage of pericardial effusion, reversible defect on a stress test resolved. Cardiac catheterization revealed normal coronary arteries. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Stress test; Tamponade; Ischemia; Pericardial effusion
Dear Editor,
Pericardial effusion as an incidental finding on a nuclear study was previously described [1,2]. However, pericardial effusion influencing reversibility on the nuclear images has not been reported. 1. Case report
rales and expiratory wheezes. Bilateral 2+ pitting edema of the lower extremities was noted. His electrocardiogram demonstrated sinus tachycardia with a ventricular rate in the 120's, possible left atrial enlargement, and voltage criteria for left ventricular hypertrophy. A portable chest radiograph showed cardiomegaly with mild pulmonary vascular congestion. The first set of cardiac markers revealed a troponin I of b0.05 ng/ml, which got elevated on the second set, and peaked at 0.145 ng/ml. His brain natriuretic peptide was 462 pg/ml (normal reference value b 100 pg/ml).
A 47 year old male with a past medical history of poorly controlled hypertension, diabetes mellitus type II and obesity presented to the emergency department with a sharp, nonradiating substernal chest pain of three-day duration. His chest pain was intermittent and often associated with shortness of breath and diaphoresis. He also noted symptoms of orthopnea and lower extremity edema. On physical examination, he was in no distress. His blood pressure was 230/120 and heart rate was 100 beats/min. Cardiovascular exam revealed normal sounds and a grade 2/6 systolic ejection murmur. The jugular venous pulse was difficult to appreciate. Lung exam was remarkable for bilateral ⁎ Corresponding author. 2A Columbia Drive Suite 5074, Tampa, FL 33616, United States. Tel.: +1 813 259 0660, 813 259 0992. E-mail addresses: [email protected], [email protected] (M. Guglin). 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.05.053
Fig. 1. Nuclear images before pericardial window.
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C. Mateja et al. / International Journal of Cardiology 137 (2009) e33–e34
Fig. 2. Nuclear images after pericardial window.
Once adequate blood pressure control was obtained, an adenosine nuclear stress test with thallium imaging was obtained to rule out cardiac ischemia. It was read as positive, with moderate areas of decreased perfusion in the lateral and inferolateral walls suggestive of moderate inferolateral ischemia. scheduled as a two-day test (Fig. 1). On the same day, a 2-D echocardiogram was performed which demonstrated moderate concentric left ventricular hypertrophy with global hypokinesis and a moderately reduced LVEF of 35–40%. Other findings included a moderately dilated left atrium, mildly dilated aortic root and most notably, a large pericardial effusion. Findings consistent with tamponade physiology including right ventricular early diastolic collapse, right atrial collapse, and significant respiratory variation in the tricuspid and mitral inflow velocities were noted. The patient was taken to the operating room for a pericardial window. The patient's shortness of breath and chest pain subsequently resolved. The next day, stress considering significant changes in cardiac status that occurred after the stress test, it was decided to repeat the stress test rather than proceed with coronary angiography. The repeated test demonstrated no significant reversibility (Fig. 2). Two months later, the patient was re-admitted for another episode of chest pain, and cardiac catheterization was performed, revealing normal coronary arteries. 2. Discussion To our knowledge there has been no previous case report in the literature of documented myocardial ischemia secondary to a large pericardial effusion with tamponade physiology. The first nuclear stress test clearly shows reversibility. Coronary angiography demonstrated no evidence of significant atherosclerotic coronary artery disease to explain this pattern of ischemia on his nuclear stress. Furthermore, after
resolution of the pericardial effusion the potential ischemia completely resolved. During our literature search there were a few documented cases of incidental findings of a pericardial effusion seen with myocardial perfusion imaging. In all reported cases the authors describe the finding as being a photopenic “halo” visualized on the raw data. This “halo” effect was due to reduced tracer uptake around the heart secondary to the pericardial effusion [1–4]. Another author described a notable “rocking” motion seen on gated post-stress SPECT images [2]. Yet another case of incidental finding of pericardial effusion demonstrated the author's ability to evaluate the patient's right and left ventricular function purely based on the images seen on the SPECT pre-stress and post-stress [3]. However, none of these case images demonstrated reversible ischemia due to the pericardial effusions such as in this case presentation. This case illustrates the detrimental effects of increased pericardial pressure on not only systemic blood pressure but also on coronary perfusion. We speculate that the ischemia in the right coronary artery territory was present due to a greater degree of epicardial arterial compression from the large pericardial effusion. It should still be noted that diagnostic method of choice for pericardial effusion as well as cardiac tamponade still remains echocardiography. In summary, we report a case of false-positive nuclear stress test in a patient with large pericardial effusion and hemodynamic features of a tamponade, and normal coronary arteries. This could result from interim change in the position of the heart due to drainage of pericardial effusion in between rest and stress images, or from compression of epicardially located coronary arteries due to large effusion with elevated pericardial pressure. Acknowledgement The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [5]. References [1] Spieth ME, Schmitz SL, Tak T. Incidental pericardial effusion diagnosed by myocardial perfusion imaging. Clin Med Res 2003;1(2):141–4. [2] Askew JW, Christenson SD. Abnormalities on cardiac planar projection and tomographic images: focus on pericardial effusions. Int J Cardiol 2008;127:266–8. [3] Herzog E, Krasnow N, DePuey G. Diagnosis of pericardial effusion and its effects no ventricular function using gated Tc-99m sestamibi perfusion SPECT. Clin Nucl Med Jun 1998;23(6):361–4. [4] Patel A, Abo-Auda WS, Gupta H, Iskandrian AE. Detection of pericardial effusion during Tc-99m sestamibi cardiac imaging. J Nucl Cardiol 2003;10(1):102–4. [5] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.
Letter to the Editor
False positive stress-test in a patient with pericardial effusion Candice Mateja, Joseph Mishkin, Malika George, Hemant Chheda, Maya Guglin ⁎ University of South Florida, FL, United States Tampa General Hospital, Tampa, FL, United States Received 16 March 2008; accepted 29 May 2008 Available online 3 September 2008
Abstract We report a case of false positive stress test in a patient with cardiac tamponade. After the drainage of pericardial effusion, reversible defect on a stress test resolved. Cardiac catheterization revealed normal coronary arteries. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Stress test; Tamponade; Ischemia; Pericardial effusion
Dear Editor,
Pericardial effusion as an incidental finding on a nuclear study was previously described [1,2]. However, pericardial effusion influencing reversibility on the nuclear images has not been reported. 1. Case report
rales and expiratory wheezes. Bilateral 2+ pitting edema of the lower extremities was noted. His electrocardiogram demonstrated sinus tachycardia with a ventricular rate in the 120's, possible left atrial enlargement, and voltage criteria for left ventricular hypertrophy. A portable chest radiograph showed cardiomegaly with mild pulmonary vascular congestion. The first set of cardiac markers revealed a troponin I of b0.05 ng/ml, which got elevated on the second set, and peaked at 0.145 ng/ml. His brain natriuretic peptide was 462 pg/ml (normal reference value b 100 pg/ml).
A 47 year old male with a past medical history of poorly controlled hypertension, diabetes mellitus type II and obesity presented to the emergency department with a sharp, nonradiating substernal chest pain of three-day duration. His chest pain was intermittent and often associated with shortness of breath and diaphoresis. He also noted symptoms of orthopnea and lower extremity edema. On physical examination, he was in no distress. His blood pressure was 230/120 and heart rate was 100 beats/min. Cardiovascular exam revealed normal sounds and a grade 2/6 systolic ejection murmur. The jugular venous pulse was difficult to appreciate. Lung exam was remarkable for bilateral ⁎ Corresponding author. 2A Columbia Drive Suite 5074, Tampa, FL 33616, United States. Tel.: +1 813 259 0660, 813 259 0992. E-mail addresses: [email protected], [email protected] (M. Guglin). 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.05.053
Fig. 1. Nuclear images before pericardial window.
e34
C. Mateja et al. / International Journal of Cardiology 137 (2009) e33–e34
Fig. 2. Nuclear images after pericardial window.
Once adequate blood pressure control was obtained, an adenosine nuclear stress test with thallium imaging was obtained to rule out cardiac ischemia. It was read as positive, with moderate areas of decreased perfusion in the lateral and inferolateral walls suggestive of moderate inferolateral ischemia. scheduled as a two-day test (Fig. 1). On the same day, a 2-D echocardiogram was performed which demonstrated moderate concentric left ventricular hypertrophy with global hypokinesis and a moderately reduced LVEF of 35–40%. Other findings included a moderately dilated left atrium, mildly dilated aortic root and most notably, a large pericardial effusion. Findings consistent with tamponade physiology including right ventricular early diastolic collapse, right atrial collapse, and significant respiratory variation in the tricuspid and mitral inflow velocities were noted. The patient was taken to the operating room for a pericardial window. The patient's shortness of breath and chest pain subsequently resolved. The next day, stress considering significant changes in cardiac status that occurred after the stress test, it was decided to repeat the stress test rather than proceed with coronary angiography. The repeated test demonstrated no significant reversibility (Fig. 2). Two months later, the patient was re-admitted for another episode of chest pain, and cardiac catheterization was performed, revealing normal coronary arteries. 2. Discussion To our knowledge there has been no previous case report in the literature of documented myocardial ischemia secondary to a large pericardial effusion with tamponade physiology. The first nuclear stress test clearly shows reversibility. Coronary angiography demonstrated no evidence of significant atherosclerotic coronary artery disease to explain this pattern of ischemia on his nuclear stress. Furthermore, after
resolution of the pericardial effusion the potential ischemia completely resolved. During our literature search there were a few documented cases of incidental findings of a pericardial effusion seen with myocardial perfusion imaging. In all reported cases the authors describe the finding as being a photopenic “halo” visualized on the raw data. This “halo” effect was due to reduced tracer uptake around the heart secondary to the pericardial effusion [1–4]. Another author described a notable “rocking” motion seen on gated post-stress SPECT images [2]. Yet another case of incidental finding of pericardial effusion demonstrated the author's ability to evaluate the patient's right and left ventricular function purely based on the images seen on the SPECT pre-stress and post-stress [3]. However, none of these case images demonstrated reversible ischemia due to the pericardial effusions such as in this case presentation. This case illustrates the detrimental effects of increased pericardial pressure on not only systemic blood pressure but also on coronary perfusion. We speculate that the ischemia in the right coronary artery territory was present due to a greater degree of epicardial arterial compression from the large pericardial effusion. It should still be noted that diagnostic method of choice for pericardial effusion as well as cardiac tamponade still remains echocardiography. In summary, we report a case of false-positive nuclear stress test in a patient with large pericardial effusion and hemodynamic features of a tamponade, and normal coronary arteries. This could result from interim change in the position of the heart due to drainage of pericardial effusion in between rest and stress images, or from compression of epicardially located coronary arteries due to large effusion with elevated pericardial pressure. Acknowledgement The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [5]. References [1] Spieth ME, Schmitz SL, Tak T. Incidental pericardial effusion diagnosed by myocardial perfusion imaging. Clin Med Res 2003;1(2):141–4. [2] Askew JW, Christenson SD. Abnormalities on cardiac planar projection and tomographic images: focus on pericardial effusions. Int J Cardiol 2008;127:266–8. [3] Herzog E, Krasnow N, DePuey G. Diagnosis of pericardial effusion and its effects no ventricular function using gated Tc-99m sestamibi perfusion SPECT. Clin Nucl Med Jun 1998;23(6):361–4. [4] Patel A, Abo-Auda WS, Gupta H, Iskandrian AE. Detection of pericardial effusion during Tc-99m sestamibi cardiac imaging. J Nucl Cardiol 2003;10(1):102–4. [5] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.