Topic Editor: Grant E. Fraser, M.D., FRACGP, FACRRM, ASTEM

Review Date: 9/18/2012

Definition

Cardiac tamponade is a life-threatening condition in which fluid within the pericardial sac results in compression of the heart, with impaired diastolic filling and an obstructive cardiovascular shock.

Description

• Cardiac tamponade is a life-threatening emergency. Prompt diagnosis and treatment are essential
• The etiology of tamponade influences prognosis and mortality
• Pericardial fluid may consist of pus, blood, serous fluid, or gas
• This fluid creates a mass effect, with this increase in pericardial pressure, when exceeding ventricular filling pressure, will impair cardiac output
• May be due to:
• Carcinomatous infiltrate of the pericardium
• Infective (HIV, tuberculosis, fungal)
• Myxoedema
• Pericarditis with effusion
• Post-operative from cardiac surgery
• Renal failure
• Rheumatologic [Systemic Lupus Erythmetosus (SLE), Rheumatoid Arthritis (RA), Dermatomyositis]
• Ruptured myocardium
• Trauma (contusion, penetrating trauma to pericardium/myocardium)
• Vascular (dissection of coronary artery or proximal aortic aneurysm)
• May present as an acute or subacute syndrome of elevated central venous pressure (CVP) and hypotension

Epidemiology

Incidence/prevalence

• Two cases/10,000 population (United States)

Gender

• More common among males

Risk factors

• Aortic or coronary artery dissection
• Cardiac procedures - surgery
• Central line placement
• Connective tissue diseases, such as SLE, RA, or dermatomyositis
• Infections (HIV, TB, Fungal)-note that the incidence of tuberculous pericarditis and effusion remains high, especially in patients with HIV in endemic areas
• Malignancy with pericardial infiltration (lung and breast are the most common)

Etiology

• Acute: Rapid accumulation of pericardial fluid >100 mL may result in tamponade
• Aortic or coronary artery dissection
• Post-operative or post-procedure, such as cardiac catheterization, cardiac surgery, pacemaker insertion, central venous catheter, pericardiocentesis
• Penetrating or blunt cardiac trauma
• Rupture of cardiac free wall, or ventricular aneurysm (most common post-myocardial infarction)
• Sub-acute or chronic: Pericardial effusions of gradual onset can become extremely large (e.g. 2 liters) before having a significant effect on cardiac output. Causes include:
• Acute idiopathic pericarditis (20%)
• Acute myocardial infarction (8%)
• Anticoagulation, antiplatelet agents, or thrombolytic therapy
• Chronic idiopathic effusion (9%)
• Coagulopathies such as Idiopathic Thrombocytopenic Purpura (ITP)
• Collagen vascular disease (5%): SLE, RA, or dermatomyositis
• Congestive heart failure (5%)
• End-stage renal disease (6%) with uremia
• Hypothyroidism and myxedema
• Iatrogenic effusion (16%)
• Infective: Tuberculosis or bacterial infection (4%), viral (coxsackie B, influenza, infectious mononucleosis), or fungal
• Malignancy (13%): Lung or breast cancer, lymphoma
• Low-pressure tamponade: Patients with preexisting effusions who receive hemodialysis, diuretics, have acute hemorrhage or dehydration, thus reducing intravascular volume. The resulting comparatively low cardiac filling pressure can lead to reduced cardiac filling, and decreased cardiac output
• Regional tamponade: Localized hematoma after cardiac surgery or post-MI

History

• Major symptoms can include dyspnea with positioning of leaning forward or sitting in the knee-chest position to relieve the breathlessness, fatigue, weakness, near or actual syncope, and lightheadedness
• Non-specific symptoms such as generalized weakness, dizziness, syncope, dyspnea, anorexia, cough or dysphagia can be the presenting complaint in patients with impending cardiac tamponade
• Altered mentation from poor perfusion
• Nausea or abdominal pain from hepatic venous engorgement
• Taking a detailed history is advised for suspected cases as it may point toward the etiology of a pericardial effusion
• Weight loss, fatigue, or anorexia may be present in cases of systemic conditions or malignancy
• Patients with pericarditis may complain of positional chest pain (worse with being supine, improved with leaning forward)
• Patients with MI may complain of chest pain or have a history of chest pain
• Musculoskeletal pain or fever in cases of underlying connective tissue disease such as systemic lupus erythematosus, rheumatoid arthritis, rheumatic fever, polyarteritis, etc
• Uremia in cases of renal failure can lead to pericardial effusion. Symptoms of uremia can include loss of appetite, drowsiness, coma, personality change, confusion, generalized itching, pallor (from anemia)
• History of recent cardiac procedures, such as cardiac catheterization, pacemaker insertion, or other procedures. History of central venous catheter placement or pericardiocentesis
• History of HIV as this can increase risk of tuberculosis, fungal and other opportunistic causes of pericardial effusion
• Radiation therapy in case of lung, esophagus, or mediastinal cancer
• Tuberculosis pericarditis may present with symptoms of fever, night sweats, and weight loss
• Other symptoms can include:
• Anxiety
• Chest pain
• Dysphoria
• Hypotension related symptoms
• Palpitations
• Pulses may be weak or absent
• Restlessness
• Skin changes (pale, gray, or cyanosed)
• Tachypnea

Physical findings on examination

• The classic presentation of cardiac tamponade is Beck's Triad:
• Elevated jugular venous pressure
• Decreased systemic arterial pressure
• Muffled or diminished heart sounds
• Of note, tension pneumothorax may present somewhat similarly, but will have a hyperresonant to percussion hemithorax and may have tracheal deviation, along with a history of trauma
• Other signs include
• Cyanosis
• Hypotension (although hypertension may occur early, but this will be temporary and will decompensate into hypotension)
• Kussmaul sign: Paradoxical increase in venous distention and pressure during inspiration. Usually observed in patients with constrictive pericarditis, occasionally in patients with effusive-constrictive pericarditis and cardiac tamponade
• Muffled, faint, or distant heart sounds
• Pericardial rub
• Pulsus paradoxus: A systolic blood pressure reduction >10 mmHg during quiet inspiration, characteristically found in acute cardiac tamponade; however, it can occur in cases of right ventricular infarction, severe congestive cardiac failure, myocarditis, emphysema, acute asthma, hypovolemic shock, pulmonary embolism, extreme obesity, ascites
• Shock (pale, cool, clammy extremities, and poor peripheral perfusion)
• Tachycardia
• Tachypnea'y' descent is abolished in jugular venous or right atrial waveform due to increase in intrapericardial pressure, thus preventing diastolic filling of the ventricles
• Low-pressure tamponade: This is a variant of cardiac tamponade that occurs in a patient with a pericardial effusion, who develop a low central venous pressure (e.g. 6–12 mmHg) due to hypovolemic, other significant systemic illnesses, malignancy, acute hemorrhage, or diuretic use. Such patients are often weak, but normotensive, but have dyspnea on exertion, and do not have the expected pulsus paradoxus

Blood test findings

• Complete blood count (CBC): Generally not specific, but can show leukocytosis in cases of infectious pericarditis. May demonstrate thrombocytopenia in cases of ITP
• Creatine kinase and CKMB isoenzyme expected to be increased in patients with MI, myopericarditis, or cardiac trauma
• Troponin, expected to be increased in patients with MI, myopericarditis, or cardiac trauma
• Blood urea nitrogen: Uremia may be present in patients with acute renal failure (ARF) leading to pericardial effusion
• Coagulation panel: Prothombin time (PT) and partial thromboplastin time (PTT) helpful to determine bleeding risk during interventional surgical procedures
• Antinuclear antibody assay, erythrocyte sedimentation rate (ESR) or C-reactive protein, and rheumatoid factor (RF) may provide an indication of connective tissue disease
• HIV test (Western Blot and ELISA): May identify HIV-associated pericardial effusion
• PPD (Purified protein derivative) test: May point toward tuberculosis being the probable cause of a pericardial effusion

Radiographic findings

Cardiac tamponade is a clinical diagnosis; however, bedside echocardiography is available in most settings and should be used for confirmation. Other imaging studies can play an important role in assessment and in planning therapeutic interventions

• Chest x-ray (CXR): May be normal; however, features suggestive of pericardial fluid include an enlarged globular cardiac shadow without the typical hilar narrowing, once a pericardial effusion exceeds 250 mL. The pulmonary vascular is generally normal
• Other CXR findings may include:
• Bowed catheter sign in children after central venous catheter (CVC) insertion
• Epicardial fat pad sign, best seen on the lateral chest X-ray as a radiolucent line between the epicardial fat and the mediastinal fat represents the pericardial space. In cases where the fat pads are separated =2 mm, this suggests fluid within the pericardium, or another cause of thickened pericardium
• Other findings of trauma (e.g. rib fractures, pneumothorax, etc.)
• Pleural effusions
• Prominent superior vena cava reflecting increased central venous pressure (CVP)
• Water bottle-shaped heart (cardiomegaly)
• Echocardiography: Is a reliable, radiation free, portable, real time method of evaluating for pericardial fluid, pericardial clots, and evaluating the hemodynamic effects of the effusion
• Tamponade is diagnosed on echocardiography by:
• Abnormal septal motion (both ventricular and atrial septa move sharply leftward on inspiration and reverse with inspiration)
• Compression of the pulmonary trunk
• Doppler flow: An exaggerated increase through tricuspid valve (>40% variation) and exaggerated decrease (>25% variation) through mitral valve
• Reduce respiratory variation of the diameter of the inferior vena cava
• Late right atrial and early right ventricular diastolic collapse
• Swinging heart
• Other findings on 2D echocardiography which could identify a cause for tamponade:
• Annular subvalvular LV aneurysm
• Bronchogenic cyst
• Descending thoracic aorta dissection
• Enlarged left atrium
• Mitral annular calcification
• Tumors surrounding the heart
• CT imaging of the heart:
• Coronary sinus compression on CT is an early specific indicator of cardiac tamponade
• Angulation or bowing of the interventricular septum
• Deformity and compression of the cardiac chambers and other intrapericardial structures
• Pericardial effusion, which is usually large, with distended superior and inferior vena cavae
• Reflux of contrast material into the azygos vein and inferior vena cava

Other diagnostic test findings

• Electrocardiogram (ECG):Is generally not specific for cardiac tamponade, but may point to other reasons for the presentation (arrhythmia, infarction)
• The following findings are suggestive but not diagnostic for tamponade:
• Sinus tachycardia
• Low-voltage complexes and non-specific ST segment and T-wave changes, or ST-segment elevation due to pericarditis
• Electrical alternans: Characteristically seen only with a large effusion due to pendular swinging back and forth of the heart within a pericardial effusion. Alternation of QRS complexes, usually in a 2:1 ratio, on ECG findings is called electrical alternans. Other possible causes of electrical alternans are myocardial ischemia/infarction, acute PE, or tachyarrhythmias
• PR segment depression
• Pulse-oximetry: Respiratory variability is correlated with pulsus paradoxus, though not reported with cardiac tamponade. Hemodynamic compromise in patients at risk for pericardial effusion may be suspected
• Hemodynamic monitoring:
• Arterial line: Direct assessment of arterial pressure allows identification of an abnormal pulsus paradoxus
• Right heart catheterization: Characteristic hemodynamic changes associated with cardiac tamponade include:
• Right atrial pressure wave with a prominent 'x' descent (ie, forward venous flow occurs only during systole) but not a prominent 'y' descent
• Equalization of diastolic pressures (to within 3-4 mmHg) in the right atrium, right ventricle, pulmonary artery and left atrium (such that all are at average diastolic pressures at 12–25 mm/Hg in the absence of pulmonary edema)
• Pulsus paradoxus in the pulmonary artery pressure that is out of phase with the systemic pulsus paradoxus

• Cardiogenic shock
• Chronic obstructive pulmonary disease
• Congestive heart failure
• Constrictive/effusive-constrictive pericarditis
• Pulmonary embolism
• Restrictive cardiomyopathy
• Right ventricular infarction
• Tension pneumothorax

General treatment items

• Cardiac tamponade is an emergency. The patient requires continuous monitoring in a critical care area of the hospital (ED, ICU, CCU)
• Bed rest with leg elevation to increase venous return until pericardial fluid is drained
• Oxygen is indicated in patients with shock
• Administration of crystalloid for volume expansion is indicated in cases with hypotension
• Consideration of inotropic agents such as dobutamine to increase stroke volume and support systemic resistance may be indicated until pericardial effusion can be drained
• Minimize positive-end expiratory pressure and pressure support if mechanically ventilated to preserve cardiac filling
• Treatment depends on the underlying etiology of the pericardial effusion
• Definitive treatment requires drainage of the pericardial fluid and may require procedures that allow for continuing draining of accumulating fluid and/or definitive measures to stop further accumulation of fluid
• Pericardiocentesis (pericardial fluid removal) is performed for diagnostic or therapeutic purposes, including urgent management of an acute tamponade
• Subxiphoid percutaneous drainage (done using a 16- or 18-gauge needle inserted near the left xiphocostal angle, at an angle of 30-45°, aiming towards the left shoulder). This is the usual approach when no echocardiography is available to guide needle placement
• Echocardiographically guided pericardiocentesis (done whenever possible, is directed toward the region of best accessibility and greatest size of effusion)
• Percutaneous balloon pericardiotomy (a balloon is used to create a pericardial window)
• Thoracotomy with direct incision and drainage of the pericardium is typically required in cases with hemopericardium. In occasional cases, where there is fresh bleeding without clot formation, blood can be evacuated from the pericardium by needle or catheter; however, this is generally temporizing and thoracotomy is generally required
• Surgical procedures:
• Pericardio-peritoneal shunt may help in prevention of recurrent tamponade in patients with malignant pericardial effusion
• Pericardiodesis to treat recurrent tamponade or effusion
• Pericardiectomy is rarely done

Medications indicated with specific doses

• Dobutamine
• Adult Dosing
• Pediatric Dosing

Disposition

Admission criteria

• All patients with cardiac tamponade require critical care level of care

Monitoring

• Follow up requires close monitoring for recurrent effusion, generally via echocardiography on a sequential basis
• Repeat echocardiogram in patients with pericardial drains before drain removal

Complications

• Cardiac arrest
• Death
• Effusive-constrictive pericarditis
• Pulmonary edema
• Recurrent effusion
• Shock

Prognosis

• Proper diagnosis and appropriate management significantly reduces morbidity and mortality in cases of cardiac tamponade
• Acute traumatic tamponade: 70-80% survival occurs in the setting of level 1 trauma centers

ICD-9-CM

• 423.3 Cardiac tamponade

ICD-10-CM

• I31.4 Cardiac tamponade

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