Electrical Alternans with Pericardial Tamponade
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A 56-year-old woman with a 6-year history of stage II cancer of the left breast presented with progressive shortness of breath and fatigue. Physical examination revealed hypotension, tachycardia, jugular venous distention, pulsus paradoxus, and distant heart sounds; the blood pressure was 63/44 mm Hg, and the heart rate 110 beats per minute. Radiography of the chest performed with the use of portable equipment revealed the water-bottle sign (in which the rounded and enlarged cardiac silhouette on frontal chest radiography mimics the appearance of an old-fashioned water bottle), which is suggestive of pericardial effusion (Panel A). Left ventricular systolic function was moderately impaired. Such changes in the position of the heart result in beat-to-beat variation in both the amplitude and the axis of the QRS complex (electrical alternans) seen on electrocardiography (Panel B, arrows)...

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