Cough, Syncope and Pericardial Effusion

A 60yM with a history of lung cancer is brought to your ED. He complaints of worsening shortness of breath, cough and new episodes of syncope. Over the past 12 hours he has syncopized 4 times, all associated with coughing. Prior to his presentation, he has never had a syncopal episode.

Further review of his chart and records show that a CT 6 weeks ago demonstrated a small pericardial effusion.
His exam reveals the following vitals: temp 36.3C, HR 88, BP 110/72, RR 22 and O2 sat of 97% on R/A. He coughs occasionally but shows no signs of increased WOB or cyanosis, with reduced air entry bilaterally and no crackles/wheeze. JVP appears elevated at 5cm. Heart sounds are normal, without murmurs, rub or muffling. Aside from mild lower leg edema, the remainder of the exam is unremarkable. Pulsus paradoxus is not present.
Labs, aside from Hb of 94 (chronic) are essentially unremarkable.
Chest X-ray shows the following:
Known left and right lung masses. Note the enlarged cardiac silhouette.
ECG is below:
No electrical alternans. Normal QRS voltage.

Bedside echo is performed, revealing a large pericardial effusion. The patient is admitted with an emergent echo booked for the following morning. The echo, as seen below (sorry no video, only still image), confirms the presence of a large effusion with RV collapse and tamponade physiology.

Check out this interesting site I just discovered: http://www.wikiecho.org/wiki/Pericardial_tamponadeLots of interesting echo tidbits.
A quick survey of the literature found two case reports of patients experiencing syncope with cough, and associated pericardial effusions: here and here. Both patients improved after the effusions were tapped.
Cough syncope is poorly understood, but is thought to be multifactorial. This paper by Benditt et al showed that in patients with cough syncope, there is a more exaggerated drop in blood pressure in response to cough compared to patients with other causes of syncope. Furthermore, there is relative bradycardia inappropriate for the hypotensive drop. This is thought to be due to changes in intrathoracic pressure and drop in venous return.
It is possible that in the presence of a sizable effusion, the patient presented here was unable to compensate for the drop in BP, thus resulting in new syncopal episodes. He was essentially in pre-tamponade state. In one case from the literature echo performed prior to and  immediately following a coughing spell demonstrated a brief tamponade state that resolved shortly after the coughing ended.
Case Resolution:
The patient presented here undergoes pericardiocentesis at the time of formal echo, and his symptoms resolve, including resolution of cough-induced syncope.
Lessons learned:
  • New cough syncope – consider the contributing factors, investigation should include echocardiogram, including bedside ultrasound.
  • Large pericardial effusions coupled with cough can transiently progress to a brief tamponade state.
References
  1. Saseedharan S, et al. Unusual presentation of pericardial effusion. Indian J Crit Care Med. 2012 Oct-Dec; 16(4): 219–221. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3610457/
  2. El-Osta H and Ashfaq S. Cough-induced syncope as an unusual manifestation of pericardial effusion. Kansas J Med. 2008. 53-55. http://www.docstoc.com/docs/48034017/Cough-Induced-Syncope-as-an-Unusual-Manifestation-of-Pericardial
  3. Benditt DG et al. Effect of cough on heart rate and blood pressure in patients with “cough syncope.” Heart Rhythm. 2005. Aug 2 (8)807-813 http://www.ncbi.nlm.nih.gov/pubmed/16051114
  4. WikiEcho http://www.wikiecho.org/wiki/Pericardial_tamponade

Author: Elisha Targonsky

Elisha T is a community emergency physician in Canada. Interests include teaching and social media in medical education. Supporter of the #FOAM and #FOAMed

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