(241) Hypertensive Emergency and Pulmonary Edema as an Atypical Presentation of Cardiac Tamponade

Introduction: Cardiac tamponade typically presents with Beck’s triad: hypotension, jugular venous distention and muffled heart sounds. However, in some cases, patients can present in early phases of tamponade before hypotension develops and can have atypical presentations, such as hypertension and pulmonary edema.Hypertensive emergency and pulmonary edema in setting of cardiac tamponade are rare and may lead to diagnostic confusion. Our case highlights clinical features, diagnostic challenges, and management of an elderly patient presenting with this uncommon manifestation.

Description: 81-year-old female with past medical history of essential thrombocytosis, hypertension and iron deficiency anemia presented to emergency department (ED) with worsening dyspnea.According to her husband, she was complaining of progressively worsening shortness of breath for one day.On day of presentation, she woke up with severe dyspnea.She denied recent sick contacts and had no history of heart failure. She reported no orthopnea. She had COVID-19 in December 2023, after which she had persistent dyspnea. Despite participation in pulmonary rehabilitation and physical therapy,she remained severely limited in her physical activity.In ED,her vitals showed blood pressure of 176/121 mmHg.Laboratory tests revealed a proBNP of 8269 pg/mL. Chest x ray was consistent with pulmonary edema.Bedside echocardiography (ECHO), followed by a stat ECHO, confirmed moderate pericardial effusion with tamponade physiology and Right ventricular collapse.Troponins were normal.During examination, she experienced profound hypoxia to low 60s, became obtunded and subsequently required intubation. She was admitted to ICU, cardiothoracic surgery was consulted for an emergent pericardial window.Patient had good outcomes after procedure

Discussion: This case underscores importance of POCUS in timely diagnosis of early phases of cardiac tamponade, specifically in atypical presentations, and need to consider cardiac tamponade in differential diagnosis of patients presenting with dyspnea and hypertension, particularly in those with known risk factors.Prompt ECHO evaluation and intervention are critical to prevent severe complications and mortality. Our case highlights diverse clinical manifestations of cardiac tamponade and need for vigilance in diagnosis