CHEST Guidelines-An-Elderly-Man-With-Dyspnea-and-Chest-Pain

An-Elderly-Man-With-Dyspnea-and-Chest-Pain_chest

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This medical case report details the condition of an 87-year-old man with a history of rheumatoid arthritis and interstitial lung disease, presenting with increasing dyspnea on exertion and new left-sided chest pain. Initial evaluations revealed a circumferential pericardial effusion and a large pulmonary embolus (PE) in the left main pulmonary artery.<br /><br />Upon transfer to the hospital's emergency department (ED), the patient showed a heart rate of 133 beats/min in atrial fibrillation and low voltage in all ECG leads. A transthoracic echocardiogram raised concerns for cardiac tamponade (pretamponade) due to right ventricular (RV) diastolic collapse, leading to his ICU admission. An immediate pericardiocentesis was performed, removing 800 mL of bloody fluid, but the patient subsequently developed refractory shock.<br /><br />The case discussion highlights the identification of RV failure stemming from massive PE as the shock's primary cause. Despite the successful evacuation of pericardial effusion, the increased RV filling post-procedure revealed the RV's inability to cope with high pulmonary artery pressures due to PE, manifesting in a clinical shock state.<br /><br />The report recognizes GDE's (Goal-Directed Echocardiography) significance in evaluating pericardial effusions and managing shock. Potential complications from pericardiocentesis, though rare, may include procedural injuries and require vigilant monitoring via ultrasound to detect. Furthermore, the coexistence of pericardial tamponade and massive PE was noted, often observed in advanced malignancy contexts.<br /><br />After the pericardiocentesis, the patient's condition necessitated inotropic and vasopressor support to stabilize his hemodynamics. Further treatment of metastatic adenocarcinoma found in the pericardial fluid was halted following the patient's palliative care decision. The case emphasizes the critical role of immediate GDE post-pericardiocentesis to detect RV failure risk, crucial in patients with coexisting PE. The patient was discharged to hospice care.

Keywords

rheumatoid arthritis

interstitial lung disease

dyspnea

pericardial effusion

pulmonary embolus

atrial fibrillation

cardiac tamponade

pericardiocentesis

Goal-Directed Echocardiography

metastatic adenocarcinoma