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Triage strategy for urgent management of cardiac tamponade

A position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.

Summary and Recommendations

Prompt recognition of cardiac tamponade is critical since the underlying hemodynamic disorder can lead to death if not resolved by percutaneous or surgical drainage of the pericardium. Nevertheless 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.

The WG on Myocardial and Pericardial Diseases issued this position statement in order to reply to specific questions:
1. Which patients need immediate drainage of the pericardial effusion?
2. Is echocardiography sufficient for guidance of pericardiocentesis or should patient be taken to the cardiac catheterization laboratory?
3. Who should be transferred to specialized/tertiary institution or surgical service?
4. What type of medical support is necessary during transportation?
Current European guidelines published in 2004 by the European Society of Cardiology (1) do not cover these issues and no additional guidelines are available from major medical and Cardiology societies.

Pericardial Disease

In the document the clinical diagnosis reviewed and specific recommendations for management of cardiac tamponade are provided. They are briefly listed here:

Recommendation (Clinical Diagnosis):
•    Cardiac tamponade should be suspected in patients presenting with hypotension, jugular venous distension, pulsus paradoxus, tachycardia, tachypnea and/or severe dyspnea;
•    Additional signs may include low QRS voltages, electrical alternance, enlarged cardiac silhouette on chest X ray.

Recommendation (Imaging):
•    Echocardiography is the diagnostic method of choice in suspected cardiac tamponade and should be carried out without delay.
•    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):

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

Recommendation (indication for drainage):
•    Pericardial drainage is indicated for each case with established diagnosis of cardiac tamponade. If the patient is hemodynamically stable the procedure should be performed within 12-24 hours from diagnosis, after obtaining laboratory results including the blood counts.
•    Indications for urgent surgical treatment of cardiac tamponade include hemopericardium due to type A aortic dissection, ventricular free wall rupture in acute myocardial infarction, trauma, or purulent effusion in unstable septic patients, and loculated effusions that can not be managed percutaneously.
•    In patients with cardiac tamponade a stepwise scoring system may be useful for the triage of patients (Figure). A total score ≥6 warrants immediate pericardiocentesis in the absence of contraindications. In rapidly deteriorating patients with iatrogenic hemopericardium or any other very unstable patient pericardial drainage should be performed without any delay for laboratory tests but treating anticoagulation (protamine), prolonged INR (fresh frozen plasma) and/or anemia (plasma-free blood transfusion) simultaneously with the drainage of the pericardium.

Recommendation (Guidance for pericardiocentesis):
•    Echocardiography is mandatory to guide pericardiocentesis and select the approach (intercostal vs. subxiphoid), except in case of life threatening tamponade.
•    Fluoroscopy can be considered for early diagnosis and rescue pericardiocentesis especially for iatrogenic effusions after specific interventional techniques (i.e. radiofrequency ablation, other percutaneous interventions), although echocardiography should be immediately available as well.

Recommendation  (Prolonged drainage):
•    Drainage of more than 1 liter effusion from the pericardial space should be avoided and prolonged catheter drainage should be provided for the remaining effusion
•    Prolonged pericardial drainage can be discussed in selected cases, especially for the management of neoplastic effusions, in order to prevent recurrence of tamponade.

Urgent pericardiocentesis or drainage of pericardial effusion is indicated for each patient with established diagnosis of cardiac tamponade and hemodynamic shock. The decision to drain an effusion and to do it immediately, urgently or schedule the procedure electively must take into account the clinical presentation, changes in the hemodynamic status over time (in the range of several minutes to several hours depending on the aetiology), the risk-benefit ratio of the procedure and the echocardiographic findings.
Since cardiac tamponade can develop slowly, and the symptoms and signs are neither highly sensitive nor specific, Halpern et al. (2) introduced a scoring index to guide the decision for pericardial drainage, based on effusion size, echocardiographic assessment of hemodynamics, and clinical factors. On the basis of currently available data, and the consensus of experts we propose a new stepwise scoring system for the triage of patients requiring pericardiocentesis (Figure). The scoring system should be applied for the triage cardiac tamponade without haemodynamic shock, where immediate pericardiocentesis is mandatory and life saving.


A new step-wise scoring system has been proposed in this statement to provide additional support to clinicians about the selection of high-risk patients that would need an immediate intervention and of those patients that should be transferred to specialized institutions. Definitive treatment is pericardiocentesis or surgical drainage of pericardial effusion that are life-saving procedures. Further prospective validation of the proposed management strategy is warranted.


  1.  Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH; Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. 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. Halpern DG, Argulian E, Briasoulis A, Chaudhry F, Aziz EF, Herzog E. A novel pericardial effusion scoring index to guide decision for drainage. Crit Pathw Cardiol. 2012;11:85-8.

Notes to editor

Authors : Arsen D. Ristic, Massimo Imazio, Yehuda Adler, Aristides Anastasakis, Luigi P. Badano, Antonio Brucato, Alida L. P. Caforio, Olivier Dubourg, Perry Elliott, Juan Gimeno, Tiina Helio, Karin Klingel, Ales Linhart, Bernhard Maisch, Bongani Mayosi, Jens Mogensen, Yigal Pinto, Hubert Seggewiss, Petar M. Seferovic, Luigi Tavazzi,Witold Tomkowski, and Philippe Charron.
Eur Heart J. 2014 Jul 7. pii: ehu217. [Epub ahead of print]

Presented by:
Massimo Imazio
Cardiology Department, Maria Vittoria Hospital and University of Torino, Italy.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.