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Is pulmonary hypertension protective against cardiac tamponade? A systematic review

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Abstract

The presence of pulmonary hypertension (PH) may affect whether cardiac tamponade physiology develops from a pericardial effusion. Specifically, the increased intracardiac pressure and right ventricular hypertrophy associated with PH would seemingly increase the intrapericardial pressure threshold at which the right-sided chambers collapse. In this systematic review, we examined the impact of PH on the incidence, in-hospital and long-term mortality, and echocardiographic findings of patients with cardiac tamponade. Using the PRISMA guideline, a systematic search was conducted in PubMed, Academic Search Premier, Web of Science, Google Scholar, and the Cochrane Database for studies investigating PH and cardiac tamponade. The Newcastle–Ottawa Scale was used to analyze the quality of returned studies. Primary outcomes included the incidence of cardiac tamponade, as well as in-hospital and long-term mortality rates. Secondary outcomes were the presence or absence of echocardiographic findings of cardiac tamponade in patients with PH. Forty-three studies (9 cohort studies and 34 case reports) with 1054 patients were included. The incidence of cardiac tamponade was significantly higher in patients with PH compared to those without PH, 2.0% (95% CI 1.2–3.2%) vs. 0.05% (95% CI 0.05–0.05%), p < 0.0001, OR 40.76 (95% CI 24.8–66.9). The incidence of tamponade in patients with a known pericardial effusion was similar in those with and without PH, 20.3% (95% CI 12.0–32.3%) and 20.9% (95% CI 18.0–24.1%), p = 0.9267, OR 0.97 (95% CI 0.50–1.87). In patients with tamponade, those with PH demonstrated a significantly higher in-hospital mortality than those without PH, 38.8% (95% CI 26.4–52.8%) vs. 14.4% (95% CI 14.2–14.6%), p < 0.0001, OR 3.77 (95% CI 2.12–6.70). Long-term mortality in patients with tamponade was significantly lower in those with PH than in those without PH, 45.5% (95% CI 33.0–58.5%) vs. 59.1% (95% CI 54.7–63.4%), p = 0.0258, OR 0.576 (95% CI 0.33–1.01). However, after stratifying by non-malignant etiologies, the long-term mortality benefit for those with PH disappeared. In the studies that described specific echocardiographic findings of cardiac tamponade, only 10.5% of patients with PH and tamponade showed right atrial and right ventricular collapse. When evaluating patients with pericardial effusions, physicians must recognize the effects of underlying PH on the incidence, in-hospital and long-term mortality rates, and potentially atypical echocardiographic presentation of cardiac tamponade.

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All data supporting the findings of this study are available within the paper and its Supplementary Information. Any additional data and calculations can be made available upon request.

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Acknowledgements

None.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA

    Robert James Adrian, Andrew Liteplo & Hamid Shokoohi

  2. Department of Emergency Medicine, Rutgers New Jersey Medical School, 185 S. Orange Ave, Newark, NJ, 07103, USA

    Stephen Alerhand

  3. Brigham and Women’s Hospital, 75 Francis St, Boston, MA, 02115, USA

    Robert James Adrian

Authors
  1. Robert James Adrian
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  2. Stephen Alerhand
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  3. Andrew Liteplo
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  4. Hamid Shokoohi
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Robert James Adrian, Stephen Alerhand, Andrew Liteplo, and Hamid Shokoohi. The first draft of the manuscript was written by Robert James Adrian and Stephen Alerhand and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Robert James Adrian.

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Ethical approval

This systematic review adheres to the ethical guidelines outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement.

Human and animal rights

As this systematic review involves the synthesis of data from previously published studies, no direct involvement of human or animal subjects occurred during this research, therefore the study was exempt from IRB systematic reviews. No studies were reported involving animal subjects in their studies.

Informed consent

Considering the established ethical guidelines, all included studies in this systematic review obtained appropriate ethical approval and informed consent from human participants, where applicable, as detailed by the original authors.

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Appendices

Appendix 1. Search strategy

Pubmed: 101

((((("pulmonary hypertension" or "pulmonary arterial hypertension" or “cor pulmonale”) AND ("cardiac Tamponade" OR "pericardial tamponade" OR "tamponade" OR "atypical tamponade")) NOT (child)) NOT (children)) NOT (neonate)) NOT (dissection).

Academic Search Premier: 45

AB pulmonary hypertension AND AB tamponade.

Google Scholar: 29

Allintitle: tamponade pulmonary hypertension -child -neonate -children -pediatric -pediatrics -dissection.

Web of Science:109

((ALL = ("tamponade") AND ALL = ("pulmonary hypertension")) OR (ALL = ("tamponade") AND ALL = ("pulmonary arterial hypertension")) OR ALL = ("tamponade") AND (ALL = ("tamponade") AND ALL = ("cor pulmonale"))) NOT ALL = (child) NOT ALL = (juvenile) NOT ALL = (neonate) NOT ALL = (dissection) NOT ALL = children.

Cochrane Library Database

(Pulmonary hypertension):ti,ab,kw AND (tamponade):ti,ab,kw.

Cochrane Reviews: 0

Cochrane Protocols: 0

Trials: 11

Editorials: 0

Appendix 2

Newcastle–Ottawa Scale assessing quality of cohort studies

Cohort studies

Selection

(maximum of 4)

Comparability

(maximum of 2)

Outcome

(maximum of 3)

Total

(maximum of 9)

Krikorian, 1978 [50]

3

0

3

6

Masuyama, 1993 [14]

2

1

2

5

Hemnes, 2008 [52]

4

0

3

7

Artaud-Macari, 2013 [86]

1

0

1

2

Fenstad, 2013 [12]

4

1

3

8

Honeycutt, 2013 [87]

3

0

3

6

Shimony, 2013 [13]

4

0

3

7

Arnott, 2018 [10]

3

0

3

6

Hosoya, 2018 [88]

3

0

3

6

  1. Scores closer to 0 represent studies of lower quality, while scores closer to 9 are considered higher quality

Appendix 3

Echocardiography of patients from case reports with PH and cardiac tamponade

Study

RAC

RVC

IVCP

IRV

LAC

LVC

Akinci, 2002 [17]

ns

–

ns

ns

ns

–

Gollapudi, 2005 [75]

ns

–

 + 

ns

ns

 + 

Liou, 2005 [58]

ns

–

ns

 + 

ns

–

Aqel, 2008 [26]

ns

–

ns

ns

ns

 + 

Mars, 2010 [25]

–

–

 + 

ns

 + 

 + 

Dunne, 2011 [56]

50%

25%

25%

25%

25%

25%

Nafsi, 2011 [51]

–

–

ns, but “no tamponade physiology”

Çilingiroğlu, 2012 [32]

–

–

–

–

ns

–

Fenstad, 2013 [12]

36%

0%

ns

100%

57%

ns

Singh, 2014 [23]

–

–

ns

ns

ns

 + 

Adams, 2015 [21]

–

–

 + 

 + 

 + 

–

Alzahrani, 2014 [33]

ns, but “no signs of tamponade”

Kandasamy, 2014 [77]

ns

–

ns

ns

 + 

 + 

Ushakumari, 2015 [90]

 + 

 + 

ns

ns

ns

–

Vallabhajosyula, 2015 [22]

–

–

 + 

 + 

 + 

ns

Malahfji, 2018 [36]

–

–

ns

 + 

ns

ns

Bibas, 2019 [24]

–

–

ns

ns

ns

 + 

Ruopp, 2019 [40]

 + 

 + 

ns

ns

ns

ns

Venkatesh, 2019 [39]

ns, but “no echocardiographic evidence of tamponade”

Kumar, 2020 [49]

–

–

ns

ns

ns

 + 

Paulraj, 2020 [19]

–

–

 + 

 + 

 + 

ns

Perez, 2020 [76]

–

–

ns

ns

 + /LHC

 + /LHC

Poorsattar, 2020 [18]

–

–

ns

 + 

 + 

 + 

Vinter, 2020 [60]

–

–

ns

 + 

ns

 + 

Shadrin, 2020 [20]

ns, but “no signs”

Aval, 2021 [57]

ns

–

 + 

ns

 + 

 + 

Baragé, 2021 [16]

ns

–

 + 

ns

 + 

 + 

Duoen, 2021 [59]

–

–

ns

 + 

ns

ns

  1. RAC right atrial collapse, RVC right ventricular collapse, IVCP inferior vena cava plethora, IRV increased respiratory variation, LAC left atrial collapse, LVC left ventricular collapse, ns not specified, LHC  “left heart collapse”

Appendix 4

Are patients with PH protected from the development of cardiac tamponade or its associated mortality?

Outcome

Patients with PH (%)

Patients without PH (%)

Significance

Odds ratio

Are patients with PH protected?

Incidence of tamponade

(no known pericardial effusion)

2.0

0.05

p < 0.0001

40.76

No

Incidence of tamponade

(known pericardial effusions)

20.3

20.9

p = 0.9267

0.97

No

In-hospital mortality

38.8

14.4

p < 0.0001

3.77

No

Long-term mortality

45.5

59.1

p = 0.0258

0.58

Yes*

  1. *No, if stratified by non-malignant etiology

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Adrian, R.J., Alerhand, S., Liteplo, A. et al. Is pulmonary hypertension protective against cardiac tamponade? A systematic review. Intern Emerg Med (2024). https://doi.org/10.1007/s11739-024-03566-y

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