Wallach's Interpretation of Diagnostic Tests: Pathways to Arriving at a Clinical Diagnosis by Mary A. Williamson Mt(ascp) Phd, L. Michael Snyder Md Page B
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loculations, pericardial thickening). Often, concern of tamponade makes echocardiography the imaging modality of choice for clinically tenuous patients due to its mobility.
Tuberculin skin test or interferon-gamma release assay : Evaluation to rule out TB is recommended for all patients. Additional diagnostic testing for TB, like AFB cultures, should be performed on patients at increased risk on the basis of epidemiologic and clinical factors.
Cultures : Cultures of blood and other potentially infected specimens should be submitted for patients with significant fever, signs of sepsis, or systemic or local infection.
Histology : Pericardiocentesis (and occasionally pericardial biopsy) should be performed for patients with clinically significant tamponade or persistent effusions. Pericardiocentesis is recommended for patients in whom pyogenic, tuberculous, or malignant pericardial disease is suspected. As most forms of pericarditis are viral in etiology, the diagnostic yield of routine pericardiocentesis has a low diagnostic yield (7%).
Recommended tests for pericardial fluid include
Histopathologic and cytologic examination of tissue and fluid.
Bacterial and mycobacterial stains and culture.
Triglyceride concentration for chylous fluid.
Adenosine deaminase and M. tuberculosis PCR, if tuberculous pericarditis is suspected.
Other specific diagnostic tests, like fungal cultures or PCR, are performed based on clinical suspicion.
Core laboratory: CBC, electrolytes, tests of renal function and thyroid function, and plasma troponin concentration. ANA titers, anti-dsDNA, and serum complement are recommended for patients when an autoimmune cause is suspected. Note: protein, glucose, LDH, RBC count, and WBC count cannot distinguish exudative from transudative effusions and are usually noncontributory in establishing a diagnosis.
Serology: HIV should be considered. Pericardial disease is relatively common in HIV-infected patients. Furthermore, HIV infection predisposes patients to mycobacterial infections. Viral diagnostic testing, including serology, has low diagnostic yield and is not routinely recommended.
Suggested Readings
Ben-Horin S, Bank I, Shinfeld A, et al. Diagnostic value of the biochemical composition of pericardial effusions in patients undergoing pericardiocentesis. Am J Cardiol. 2007;99:1294–1297.
Hidron A, Vogenthaler N, Santos-Preciado JI, et al. Cardiac involvement with parasitic infections. Clin Microbiol Rev. 2010;23:324–349.
Lange RA, Hillis D. Acute pericarditis. N Engl J Med. 2004;351:2195–2202.
Levy PY, Cory R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine (Baltimore). 2003;82:385–391.
CHEST PAIN: HYPERADRENERGIC STATES
Syndromes of catecholamine excess may cause chest pain from increased heart rate and peripheral vasoconstriction, resulting in a mismatch of oxygen supply and demand. Severe presentations may result in type 2 MI.
Autoregulation of tissue blood flow and cardiac output are able to adapt to a wide range of perturbations in hear rate and blood pressure, particularly those that are chronic in nature. Symptoms are more likely to occur during periods of acute changes induced by either exogenous administration of catecholamines (cocaine, methamphetamines) or intrinsic paroxysmal episodes (stress cardiomyopathy, pheochromocytoma).
Definition
Cocaine intoxication : Chest pain is the most common reason for cocaine users to seek medical attention with 64,000 ED visits per year in the United States (50% admitted). Six percent of chest pain episodes are MI. Aortic dissection is a rare consequence of cocaine use. Cocaine is both sympathomimetic and thrombogenic and accelerates atherosclerotic deposition—as a result, ischemic damage can manifest as either type I MI (ruptured plaque) or type 2 MI (either severe epicardial spasm or increased oxygen demand).
Methamphetamine
Tuberculin skin test or interferon-gamma release assay : Evaluation to rule out TB is recommended for all patients. Additional diagnostic testing for TB, like AFB cultures, should be performed on patients at increased risk on the basis of epidemiologic and clinical factors.
Cultures : Cultures of blood and other potentially infected specimens should be submitted for patients with significant fever, signs of sepsis, or systemic or local infection.
Histology : Pericardiocentesis (and occasionally pericardial biopsy) should be performed for patients with clinically significant tamponade or persistent effusions. Pericardiocentesis is recommended for patients in whom pyogenic, tuberculous, or malignant pericardial disease is suspected. As most forms of pericarditis are viral in etiology, the diagnostic yield of routine pericardiocentesis has a low diagnostic yield (7%).
Recommended tests for pericardial fluid include
Histopathologic and cytologic examination of tissue and fluid.
Bacterial and mycobacterial stains and culture.
Triglyceride concentration for chylous fluid.
Adenosine deaminase and M. tuberculosis PCR, if tuberculous pericarditis is suspected.
Other specific diagnostic tests, like fungal cultures or PCR, are performed based on clinical suspicion.
Core laboratory: CBC, electrolytes, tests of renal function and thyroid function, and plasma troponin concentration. ANA titers, anti-dsDNA, and serum complement are recommended for patients when an autoimmune cause is suspected. Note: protein, glucose, LDH, RBC count, and WBC count cannot distinguish exudative from transudative effusions and are usually noncontributory in establishing a diagnosis.
Serology: HIV should be considered. Pericardial disease is relatively common in HIV-infected patients. Furthermore, HIV infection predisposes patients to mycobacterial infections. Viral diagnostic testing, including serology, has low diagnostic yield and is not routinely recommended.
Suggested Readings
Ben-Horin S, Bank I, Shinfeld A, et al. Diagnostic value of the biochemical composition of pericardial effusions in patients undergoing pericardiocentesis. Am J Cardiol. 2007;99:1294–1297.
Hidron A, Vogenthaler N, Santos-Preciado JI, et al. Cardiac involvement with parasitic infections. Clin Microbiol Rev. 2010;23:324–349.
Lange RA, Hillis D. Acute pericarditis. N Engl J Med. 2004;351:2195–2202.
Levy PY, Cory R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusions. Medicine (Baltimore). 2003;82:385–391.
CHEST PAIN: HYPERADRENERGIC STATES
Syndromes of catecholamine excess may cause chest pain from increased heart rate and peripheral vasoconstriction, resulting in a mismatch of oxygen supply and demand. Severe presentations may result in type 2 MI.
Autoregulation of tissue blood flow and cardiac output are able to adapt to a wide range of perturbations in hear rate and blood pressure, particularly those that are chronic in nature. Symptoms are more likely to occur during periods of acute changes induced by either exogenous administration of catecholamines (cocaine, methamphetamines) or intrinsic paroxysmal episodes (stress cardiomyopathy, pheochromocytoma).
Definition
Cocaine intoxication : Chest pain is the most common reason for cocaine users to seek medical attention with 64,000 ED visits per year in the United States (50% admitted). Six percent of chest pain episodes are MI. Aortic dissection is a rare consequence of cocaine use. Cocaine is both sympathomimetic and thrombogenic and accelerates atherosclerotic deposition—as a result, ischemic damage can manifest as either type I MI (ruptured plaque) or type 2 MI (either severe epicardial spasm or increased oxygen demand).
Methamphetamine
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