History and exam

Key diagnostic factors

common

malignancy

Metastatic disease (particularly breast and lung cancer) is much more likely than primary pericardial/cardiac malignancy to cause cardiac tamponade.[27] Effusion may be secondary to cancer therapy rather than actual metastatic pericardial disease.​[26][27][28]​​

presence of other risk factors

Key risk factors include: aortic dissection, purulent pericarditis, large idiopathic pericardial effusion, tuberculosis, end-stage renal failure, hypothyroidism, and autoimmune disease.[18][29]​​[31][33]​​​[36][37]​​​​​[38]

dyspnea

Up to 90% of patients will report dyspnea.[10]

elevated jugular venous pressure (JVP)

One of the three signs of the Beck triad.

Central venous pressure is increased in an effort to maintain ventricular volumes.[10] One systematic review found that the pooled sensitivity of elevated JVP was 76% (95% CI 62% to 90%).[40]​ ​

distant heart sounds

One of the three signs of the Beck triad.

Heart sounds may be muffled secondary to large pericardial effusion.[10] One systematic review found that the pooled sensitivity of distant heart sounds was low at 28% (95% CI 21% to 35%).[40]​​

pulsus paradoxus

Refers to a reduction in systolic blood pressure >10 mmHg with inspiration. Severe pulsus paradoxus can lead to a disappearance of the peripheral pulses with inspiration. One systematic review found that the pooled sensitivity of pulsus paradoxus >10 mmHg was 82% (95% CI 72% to 92%) and that its presence in a patient with a pericardial effusion increases the likelihood of tamponade (positive likelihood ratio 3.3), while a pulsus paradoxus ≤10 mmHg makes tamponade unlikely (negative likelihood ratio 0.03).[40]

hypotension

One of the three signs of the Beck triad.

Has been reported to occur in up to 35% of patients with nontraumatic tamponade.[10]​ One systematic review found that the pooled sensitivity of hypotension was low at 26% (95% CI 16% to 36%).[40]

tachycardia

One of the most common findings in cardiac tamponade.[40] Has been reported to occur in up to 88% of patients.[10]​ One systematic review found that the pooled sensitivity of tachycardia was 77% (95% CI 69% to 85%).[40]​​

uncommon

recent cardiac surgery or intervention

Cardiac surgery or intervention is a strong risk factor for tamponade. In surgical patients, tamponade is most common following valve surgery and heart transplant and less common in isolated coronary artery bypass graft.[5][34][35]​ Rarely, tamponade may occur after thrombolysis or angioplasty, percutaneous coronary interventions, ablations, and pacemaker/defibrillator implantation.[22]

Beck triad: hypotension, distant heart sounds, and elevated JVP

Most patients will not present with all of the classic features of the Beck triad (hypotension, distant heart sounds, and elevated JVP).[10][40][41]​​ The triad was originally described in patients with acute tamponade secondary to trauma or surgery. In some medical patients, especially where the pericardial effusion has developed slowly, Beck triad may not be present at all.[40]

Other diagnostic factors

common

chest pain

Atypical, nonexertional chest pain. Has been reported to occur in 12% to 74% of patients.[10]

abdominal pain

Secondary to hepatic congestion and or hypoperfusion. Has been reported to occur in 12% to 16% of patients.[10]

uncommon

fever

May indicate underlying infective etiology. Has been reported to occur in 7% to 70% of patients.[10]

pericardial rub

More common in inflammatory etiologies of pericardial effusions. May be absent in large effusions.[2]

Risk factors

strong

malignancy

Malignancy is a common cause of hemodynamically significant pericardial effusions and, therefore, of cardiac tamponade, with lung and breast cancer the most common primary sites.[14][16][18][26] Primary malignancies of the pericardium are rare.[27]​​​​

Tamponade without inflammatory signs is more likely to be related to malignancy.​[20]

Up to 60% of malignancy-related effusions are not directly caused by the malignancy but are complications of radiation or systemic cancer therapy.[15]​​[26][27]​​​[28]

aortic dissection

Cardiac tamponade is a common and life-threatening complication of acute type A aortic dissections (AAD).[12][29]​​​ Findings from a large cohort of the International Registry of Acute Aortic Dissection found that tamponade was detected in 18.7% of patients.[30]​​

purulent pericarditis

Severe bacterial infection of the pericardium is rare but rapidly fatal and carries a high risk of tamponade.[31]​ Cardiac tamponade may occur in up to 79% of patients with purulent pericarditis.[32]​​

large idiopathic chronic pericardial effusion

Patients with large chronic effusions (>3 months) with inflammatory signs are more likely to develop tamponade than those without inflammatory signs.[20] Around one third of patients with large asymptomatic pericardial effusions will develop clinically significant tamponade.​[33]

post-cardiac surgery or intervention

Cardiac tamponade may present rapidly, secondary to hemorrhage (hemopericardium). In surgical patients, tamponade is most common following valve surgery and heart transplant and less common in isolated coronary artery bypass graft.[5][34][35]​​​ Rarely, tamponade may also occur after thrombolysis or angioplasty, percutaneous coronary interventions, ablations, and pacemaker/defibrillator implantation.[22]

Symptomatic postoperative pericardial effusion and cardiac tamponade can also occur as a late complication of cardiac surgery/intervention. One study followed up cardiac surgery patients for 6 months post-procedure and found that 6.2% of patients underwent treatment for late postoperative pericardial effusion, of whom two-thirds were classified as having tamponade.[35]​ Median delay to presentation was 11 days post-operation (range: 8-87 days).

tuberculosis (TB)

In people from endemic areas, especially in patients with HIV infection, the incidence of TB pericarditis and effusion is high. In a large urban study in the UK, TB accounted for 26% of pericardial effusions requiring surgical drainage. Most of these patients were native to areas with endemic TB.[18]

weak

autoimmune disease

There are no large studies investigating the incidence of pericardial effusion or cardiac tamponade in patients with autoimmune diseases, but most case series report frequent detection of pericardial effusion with a low incidence of tamponade.[36]

hypothyroidism

Though pericardial effusions are seen in up to 37% of patients with severe hypothyroidism, fluid accumulates slowly and tamponade rarely occurs.[15][37]​​

end-stage renal failure

Usually develops gradually so the risk of tamponade is diminished. Asymptomatic pericardial effusions are reported to occur in 70% to 100% of patients with uremic- or dialysis-related pericarditis; cardiac tamponade occurs in up to 20% of patients with dialysis-related pericarditis.[38]

anticoagulation

May increase the risk of large, hemorrhagic pericardial effusions when used in the management of anterior wall myocardial infarctions or constrictive pericarditis, or following cardiac surgery.[39]

Use of this content is subject to our disclaimer