Editor's Note: Commentary based on Ristic AD, Imazio M, Adler Y, et al. Triage strategy for urgent management of cardiac tamponade: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2014; 35: 2279–2284.

The management of pericardial disease is often simple and rewarding, but may offer unexpected challenges. Symptoms are often vague and nonspecific and physical signs are difficult to elicit and recognize. Although the European Society of Cardiology published guidelines for the diagnosis and management of pericardial diseases in 2004¹ there is a paucity of randomized, placebo-controlled trials (level of evidence A) from which to make important clinical decisions; as a result, the physician is often left to rely on clinical judgment as most data originate from small, uncontrolled trials and anecdotal experience. Moreover, in that document, little attention was given to the management of cardiac tamponade. Ristic et al attempt to narrow that knowledge gap by providing an evidence-based triage strategy². A key feature of the strategy is the development of a stepwise scoring system (total of 31 fields) with points accumulated for etiology, clinical presentation, and echocardiographic imaging. Uniquely, the score incorporates point deductions for reversible causes (e.g. autoimmune, hypothyroid), small effusions, and slowly evolving disease. Drawn from available data and expert consensus, this scoring system is both more comprehensive and cumbersome than the score proposed by Halpern et al³, although one could easily envision its configuration as an app on smart phones. Importantly, neither system has been validated prospectively. Irrespective of the score, urgent surgical management is recommended in the setting of type A aortic dissection, cardiac rupture, severe recent thoracic trauma, and iatrogenic hemopericardium that cannot be controlled percutaneously.

Based on expert opinion, transportation to a specialized facility with a physician in attendance and ECG and blood pressure monitoring is recommended if hemodynamically stable cardiac tamponade is diagnosed at a facility with limited experience in pericardial drainage. In addition, although few data are available to help select the method (percutaneous or surgical) of pericardial drainage, expert consensus dictates that surgery is warranted when the effusion 1) cannot be reached or adequately drained by a needle or catheter, 2) is purulent, or 3) is due to intrapericardial bleeding. Institutional expertise and physician comfort with pericardiocentesis is often a consideration.

The Working Group mandates echocardiographic guidance and location selection of pericardiocentesis in all but life-threatening cases and considers fluoroscopy acceptable for rescue pericardiocentesis for iatrogenic effusions; "blind" subxiphoid pericardiocentesis is strongly discouraged. Recommendations to maximize safety of the procedure (echo confirmation of catheter placement with agitated saline, aseptic technique, management of cardiac chamber perforation and vagal reactions, post-drainage observation for hemodynamic decompensation) are based on expert consensus; hemodynamic monitoring is not specifically mentioned. Rapid removal of more than 1L of fluid is strongly discouraged and based on limited data and expert opinion, prolonged pericardial drainage (until intermittent aspiration falls to < 25-30 mL/day) is recommended for neoplastic and (to a lesser extent) idiopathic effusions. Finally, a minimum of five pericardiocentesis procedures as part of cardiology and emergency medicine training is proposed.

This document is an important contribution to the field insofar as it provides the practitioner with common sense recommendations based on expert consensus and in some instances, evidence from clinical trials. However, few randomized controlled trials in cardiac tamponade exist and graded recommendations based on the level of evidence are not possible. Prospective validation of the proposed scoring system and randomized trials, as have been conducted in pericarditis⁴, are clearly warranted.

References

1. Maisch B, Seferovic PM, Ristic AD, et al: Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology. Eur Heart J 2004;25:587-610.
2. Ristic AD, Imazio M, Adler Y, et al: Triage strategy for urgent management of cardiac tamponade: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2014;35:2279-2284.
3. Halpern DG, Argulian E, Briasoulis A, et al: A novel pericardial effusion scoring index to guide decision for drainage. Crit Pathways in Cardio 2012;11:85-88.
4. Imazio M, Bobbio M, Cecchi E, et al: Colchicine in addition to conventional therapy for acute pericarditis: result of the Colchicine for acute Pericarditis (COPE) trial. Circulation 2005;112:2012-2016.

Keywords: Blood Pressure, Cardiac Tamponade, Cardiology, Drainage, Echocardiography, Electrocardiography, Emergency Medicine, Fluoroscopy, Heart Rupture, Iatrogenic Disease, Pericardial Effusion, Pericardiocentesis, Pericarditis, Prospective Studies, Triage, Visually Impaired Persons

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