Triage Strategy for Urgent Management of Cardiac Tamponade

Abstract and Introduction

Introduction

Prompt recognition of cardiac tamponade is critical since the underlying haemodynamic disorder can lead to death if not resolved by percutaneous or surgical drainage of the pericardium. Cardiac tamponade is a condition caused by the compression of the heart due to slow or rapid accumulation of fluid (exudate), pus, blood, clots, or gas within the pericardial space resulting in impaired diastolic filling and cardiac output due to increased intrapericardial pressure.

Pericardial diseases of any aetiology may cause cardiac tamponade, but with highly variable incidence reflecting the local epidemiological background (Table 1). However, all interventional procedures (i.e. percutaneous coronary intervention, transcatheter aortic valve implantation, pacemaker/implantable cardioverter defibrillator implantation, arrhythmias ablation, endomyocardial biopsy) are emerging causes of cardiac tamponade. Although rare, cardiac tamponade may also occur in pregnancy and in post-partum. Thus cardiologists should be aware of this possibility including specific contraindications for pregnancy (i.e. avoid the use of colchicine and X-ray exposure using echo-guided procedure).

Management of cardiac tamponade can be challenging because of the lack of the validated criteria for the risk stratification that should guide clinicians in the decision-making process: (i) which patients need immediate drainage of the pericardial effusion? (ii) Is echocardiography sufficient for guidance of pericardiocentesis or should patient be taken to the cardiac catheterization laboratory? (iii) Who should be transferred to specialized/tertiary institution or surgical service? (iv) What type of medical support is necessary during transportation?

Current European guidelines published in 2004 by the European Society of Cardiology do not cover these issues and no additional guidelines are available from major medical and Cardiology societies. Therefore, the aim of this position statement is to provide updated, evidence-based recommendations, when available, for triage and clinical management of patients with cardiac tamponade.

Clinical Diagnosis

Cardiac tamponade includes a haemodynamic spectrum ranging from incipient or preclinical tamponade (pericardial pressure equals right atrial pressure but it is lower than left atrial pressure) to haemodynamic shock with significant reduction of stroke volume, blood pressure, and evident pulsus paradoxus (when pericardial pressure is higher than 10–12 mmHg and in the presence of compression of right heart chambers). A detailed discussion on diagnostic issues, differential diagnosis, and available pertinent literature for this condition is included in Supplementary material online, filehttp://eurheartj.oxfordjournals.org/content/35/34/2279/suppl/DC1.

Recommendation (Clinical Diagnosis)

1. 
   Cardiac tamponade should be suspected in patients presenting with hypotension, jugular venous distension, pulsus paradoxus, tachycardia, tachypnea, and/or severe dyspnoea;
   
2. 
   Additional signs may include low QRS voltages, electrical alternans, enlarged cardiac silhouette on chest X-ray.
   

Recommendation (Imaging)

1. 
   Echocardiography is the diagnostic method of choice in suspected cardiac tamponade and should be carried out without delay.
   
2. 
   CT and CMR are not part of the routine evaluation of patients with suspected cardiac tamponade; they are useful to rule out concomitant diseases involving the mediastinum and lungs in patients with large pericardial effusions (i.e. cancer or aortic dissection).
   

Recommendation (Differential Diagnosis)

1. 
   Differential diagnosis should include constrictive pericarditis, congestive heart failure, and advanced liver disease with cirrhosis.