ESC Group Issues Triage Strategy to Manage Cardiac Tamponade
TURIN, ITALY (updated) — The European Society of Cardiology (ESC) Working Group on Myocardial and Pericardial Diseases has developed a stepwise scoring system to identify patients who need immediate pericardiocentesis and patients who can safely be transferred to a specialized institution.

The scoring system may improve the clinical management of this condition by providing a practical triage tool, which may lead to fewer treatment delays, "thus potentially improving survival, but this needs to be validated," corresponding author Dr Massimo Imazio (Maria Vitoria Hospital, Turin, Italy) told heartwire.

New guidance on how to approach cardiac tamponade is timely, given the rise in interventional procedures—among them transcatheter-valve implantation and pacemaker/ICD placements—that are "emerging causes" of this potentially lethal complication, the authors explain.

Moreover, "there is also still a need for the correct performance of pericardiocentesis in such an emergency situation," coauthor Dr Bernhard Maisch (University Hospital Giessen and Marburg and Philipps-University Marburg, Germany) told heartwire. "Particularly in smaller hospitals and in Eastern Europe, 'blind' pericardiocentesis [without echocardiography] is still carried out, which is contraindicated because of its high risk of epicardial and myocardial laceration."

The position statement was published online July 7, 2014 in the European Heart Journal.

Challenging Cases

Prompt recognition of cardiac tamponade is critical, and once it is diagnosed, patient management can be challenging because of the lack of validated criteria for risk stratification, the authors write. Moreover, the 2004 ESC guidelines on pericardial disease, the only cardiology or medical-society guidelines about this, do not cover certain important issues.

The group aimed to use evidence-based data, where possible, to determine which patients need immediate drainage of the pericardial effusion; whether echocardiography is sufficient to guide pericardiocentesis; which patients should be transferred to a specialized/tertiary institution or surgical service; and what type of medical support is needed during transportation.

To diagnose cardiac tamponade, the position statement advises that "cardiac tamponade should be suspected in patients presenting with hypotension, jugular venous distension, pulsus paradoxus, tachycardia, tachypnea, and/or severe dyspnea, [and] additional signs may include low QRS voltages, electrical alternans, and enlarged cardiac silhouette on chest X ray."

Echocardiography should be carried out without delay, they note. Cardiac computed tomography and cardiovascular MRI are useful to rule out cancer or aortic dissection in patients with large pericardial effusions. Constrictive pericarditis, congestive heart failure, and advanced liver disease with cirrhosis need to be ruled out.

Once cardiac tamponade is diagnosed, patients may require immediate, lifesaving pericardial drainage if they are in hemodynamic shock. If the patient is hemodynamically stable, the procedure should be performed within 12 to 24 hours of diagnosis, after obtaining laboratory test results including blood counts.

Patient Triage

The group developed a novel triage system, where some patients are immediately classified as requiring urgent pericardial drainage without the need for further scoring based on the presence of specific emergency criteria. For other patients—those who don't have one (or more) of five urgent conditions—a stepwise scoring system, derived from tamponade etiology, clinical presentation, and imaging findings, can be used to determine whether the patient requires pericardial drainage urgently or within 12 to 48 hours.

Patients who clearly require urgent surgical treatment without the need for further scoring are those with type A aortic dissection, ventricular free wall rupture after acute myocardial infarction, recent chest trauma, purulent effusion in unstable septic patients, and loculated effusions that cannot be managed percutaneously.

For all other patients, a score is derived, based on a patient's disease etiology (step1), clinical presentation (step 2), and imaging findings (step 3). For example, having tuberculosis, pulsus paradoxus >10 mg, and left atrial collapse are each scored as 2, for a total score of 6.

A score of 6 or more indicates that the patient requires urgent pericardiocentesis, whereas a lower score indicates that the pericardiocentesis can be postponed for up to 12 to 48 hours.

"The scoring system will help to clarify that pericardial puncture should be done correctly and offers a unique chance to clarify the different etiologies of pericardial effusions," Maisch said. "Idiopathic pericardial effusion is diagnosed much too often, because in fact, idiopathic means just that, we have not investigated thoroughly enough the pathogenesis of the underlying disease," he added.

The authors also call for more widespread, specialized physician training.

"Emergency pericardiocentesis is a lifesaving procedure, and each cardiologist working in hospitals, especially with emergency departments, should be able to perform it properly; thus, appropriate training should be planned," they write. "We propose that a minimum of five pericardiocentesis procedures should be incorporated in the training curriculum for specialization in cardiology or emergency medicine."

"Assessment of hemodynamic compromise in a patient with pericardial effusion is not always a clear-cut decision, since cardiac tamponade is a continuum rather than a simple syndrome with a yes or no threshold for diagnosis," lead author Dr Arsen D Ristic (Belgrade University School of Medicine, Serbia) commented to heartwire. Cardiac tamponade is an important medical emergency, and physicians on duty in a small hospital with no surgical backup and limited experience with pericardiocentesis can use the new scoring system to help decide whether to perform pericardiocentesis themselves, wait for a more experienced operator, or transfer the patient to a specialized institution, he added.

The group will be presenting the position statement at the upcoming ESC 2014 Congress in Barcelona, Spain.

The authors have no conflicts of interest.