Editorial
A new scoring system for the triage of cardiac tamponade Expert Review of Cardiovascular Therapy Downloaded from informahealthcare.com by Nyu Medical Center on 02/17/15 For personal use only.
Expert Rev. Cardiovasc. Ther. Early online, 1–2 (2015)
Massimo Imazio‡ Author for correspondence: Cardiology Department, Maria Vittoria Hospital and University of Torino, Torino, Italy [email protected]; [email protected]
Yehuda Adler‡ Cham Sheiba Medical Center and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Arsen D Ristic Department of Cardiology, Belgrade University School of Medicine and Clinical Centre of Serbia, Belgrade, Serbia
Philippe Charron Universite de Versailles-Saint Quentin, AP-HP, Hoˆpital Pitie-Salpeˆtrie`re, Centre de Reference Maladies cardiaques hereditaires, Paris, France
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, the 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 Working Group on Myocardial and Pericardial Diseases issued this position statement in order to reply to specific questions: Which patients need immediate drainage of the pericardial effusion?; Is echocardiography sufficient for guidance of pericardiocentesis or should patient be taken to the cardiac catheterization laboratory?; Who should be transferred to specialized/tertiary institution or surgical service?; What type of medical support is necessary during transportation? Current European guidelines published in 2004 do not cover these issues and no additional guidelines are available from major medical and cardiology societies.
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, the management of cardiac tamponade can be challenging because of the lack of the validated criteria for risk stratification that should guide clinicians in the decision-making process [1,2]. The Working Group on Myocardial and Pericardial Diseases of the European Society of Cardiology issued this position statement [3] in order to reply to specific questions: . .
‡
Authors contributed equally
.
.
Which patients need immediate drainage of the pericardial effusion? Is echocardiography sufficient for guidance of pericardiocentesis or should patient be taken to the cardiac catheterization laboratory? Who should be transferred to specialized/tertiary institution or surgical service? What type of medical support is necessary during transportation?
The current guidelines published by the European Society of Cardiology in 2004 [4] do not cover these issues and no
additional guidelines are available from major medical and cardiology societies. Urgent pericardiocentesis or drainage of pericardial effusion is indicated for each patient with established diagnosis of cardiac tamponade and cardiogenic shock. The decision to drain an effusion and doing it immediately, urgently or scheduling 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 etiology), the risk–benefit ratio of the procedure and the echocardiographic findings. Importantly, the availability of an experienced operator and local logistic issues should be also taken into account. Since cardiac tamponade can develop slowly, and the symptoms and signs are neither highly sensitive nor specific, Halpern et al. [5] introduced a scoring index to guide the decision for pericardial drainage based on effusion size and echocardiographic assessment of hemodynamic and clinical factors. However, this score requires comprehensive laboratory assessment, which might not be feasible in the emergency services worldwide. On the basis of currently available data and
KEYWORDS: cardiac tamponade . diagnosis . pericarditis . prognosis . triage
informahealthcare.com
10.1586/14779072.2015.1007127
2015 Informa UK Ltd
ISSN 1477-9072
1
Expert Review of Cardiovascular Therapy Downloaded from informahealthcare.com by Nyu Medical Center on 02/17/15 For personal use only.
Editorial
Imazio, Adler, Ristic& Charron
the consensus of experts, we propose a new stepwise scoring system for the triage of patients requiring pericardiocentesis. The rationale for the scores in each step was based upon probabilities of progression to cardiac tamponade in patients with pericardial effusion according to the published data and consensus of experts. Cardiac tamponade may be a life-threatening emergency, especially in the setting of aortic dissection, ventricular free wall rupture after acute myocardial infarction, severe chest trauma, and iatrogenic hemopericardium after interventional procedures when bleeding cannot be controlled percutaneously. In all these settings, the progression to cardiac shock and death may be quick and unexpected. For these reasons, regardless of the score, these conditions represent emergencies where urgent surgical management is required without delay. The scoring system should be applied for the triage of cardiac tamponade patients without cardiogenic shock, where immediate pericardiocentesis is mandatory and life saving. There are three steps: .
.
.
Step 1: Score the etiology. Data from a focused history and clinical presentation should help clinicians to detect potential causes of pericardial disease (especially tuberculosis, cancer) that are associated with large effusions and higher risk of a worsening of cardiac tamponade and progression to cardiogenic shock. Step 2: Score the clinical presentation. Highly symptomatic patients with worsening symptoms as well as additional physical sign of cardiac tamponade (e.g., hypotension, tachycardia, pulsus paradoxus >10 mmHg) are those with a higher risk of progression. Step 3: Score the imaging: Overt diagnostic signs of a large and worsening pericardial effusion (e.g., cardiomegaly on chest x-ray, large pericardial effusion >20 mm on echocardiography with inferior vena cava plethora and right ventricular and left atrial collapse) warrant immediate action.
References 1.
2.
3.
Imazio M, Mayosi BM, Brucato A, et al. Triage and management of pericardial effusion. J Cardiovasc Med (Hagerstown) 2010;11:928-35 Shabetai R. Pericardial effusion: haemodynamic spectrum. Heart 2004;90: 255-6
doi: 10.1586/14779072.2015.1007127
4.
A total score ‡6 indicates the need for urgent pericardiocentesis in the absence of contraindications (i.e., high INR >1.5, severe thrombocytopenia with a platelet count
A new scoring system for the triage of cardiac tamponade Expert Review of Cardiovascular Therapy Downloaded from informahealthcare.com by Nyu Medical Center on 02/17/15 For personal use only.
Expert Rev. Cardiovasc. Ther. Early online, 1–2 (2015)
Massimo Imazio‡ Author for correspondence: Cardiology Department, Maria Vittoria Hospital and University of Torino, Torino, Italy [email protected]; [email protected]
Yehuda Adler‡ Cham Sheiba Medical Center and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Arsen D Ristic Department of Cardiology, Belgrade University School of Medicine and Clinical Centre of Serbia, Belgrade, Serbia
Philippe Charron Universite de Versailles-Saint Quentin, AP-HP, Hoˆpital Pitie-Salpeˆtrie`re, Centre de Reference Maladies cardiaques hereditaires, Paris, France
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, the 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 Working Group on Myocardial and Pericardial Diseases issued this position statement in order to reply to specific questions: Which patients need immediate drainage of the pericardial effusion?; Is echocardiography sufficient for guidance of pericardiocentesis or should patient be taken to the cardiac catheterization laboratory?; Who should be transferred to specialized/tertiary institution or surgical service?; What type of medical support is necessary during transportation? Current European guidelines published in 2004 do not cover these issues and no additional guidelines are available from major medical and cardiology societies.
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, the management of cardiac tamponade can be challenging because of the lack of the validated criteria for risk stratification that should guide clinicians in the decision-making process [1,2]. The Working Group on Myocardial and Pericardial Diseases of the European Society of Cardiology issued this position statement [3] in order to reply to specific questions: . .
‡
Authors contributed equally
.
.
Which patients need immediate drainage of the pericardial effusion? Is echocardiography sufficient for guidance of pericardiocentesis or should patient be taken to the cardiac catheterization laboratory? Who should be transferred to specialized/tertiary institution or surgical service? What type of medical support is necessary during transportation?
The current guidelines published by the European Society of Cardiology in 2004 [4] do not cover these issues and no
additional guidelines are available from major medical and cardiology societies. Urgent pericardiocentesis or drainage of pericardial effusion is indicated for each patient with established diagnosis of cardiac tamponade and cardiogenic shock. The decision to drain an effusion and doing it immediately, urgently or scheduling 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 etiology), the risk–benefit ratio of the procedure and the echocardiographic findings. Importantly, the availability of an experienced operator and local logistic issues should be also taken into account. Since cardiac tamponade can develop slowly, and the symptoms and signs are neither highly sensitive nor specific, Halpern et al. [5] introduced a scoring index to guide the decision for pericardial drainage based on effusion size and echocardiographic assessment of hemodynamic and clinical factors. However, this score requires comprehensive laboratory assessment, which might not be feasible in the emergency services worldwide. On the basis of currently available data and
KEYWORDS: cardiac tamponade . diagnosis . pericarditis . prognosis . triage
informahealthcare.com
10.1586/14779072.2015.1007127
2015 Informa UK Ltd
ISSN 1477-9072
1
Expert Review of Cardiovascular Therapy Downloaded from informahealthcare.com by Nyu Medical Center on 02/17/15 For personal use only.
Editorial
Imazio, Adler, Ristic& Charron
the consensus of experts, we propose a new stepwise scoring system for the triage of patients requiring pericardiocentesis. The rationale for the scores in each step was based upon probabilities of progression to cardiac tamponade in patients with pericardial effusion according to the published data and consensus of experts. Cardiac tamponade may be a life-threatening emergency, especially in the setting of aortic dissection, ventricular free wall rupture after acute myocardial infarction, severe chest trauma, and iatrogenic hemopericardium after interventional procedures when bleeding cannot be controlled percutaneously. In all these settings, the progression to cardiac shock and death may be quick and unexpected. For these reasons, regardless of the score, these conditions represent emergencies where urgent surgical management is required without delay. The scoring system should be applied for the triage of cardiac tamponade patients without cardiogenic shock, where immediate pericardiocentesis is mandatory and life saving. There are three steps: .
.
.
Step 1: Score the etiology. Data from a focused history and clinical presentation should help clinicians to detect potential causes of pericardial disease (especially tuberculosis, cancer) that are associated with large effusions and higher risk of a worsening of cardiac tamponade and progression to cardiogenic shock. Step 2: Score the clinical presentation. Highly symptomatic patients with worsening symptoms as well as additional physical sign of cardiac tamponade (e.g., hypotension, tachycardia, pulsus paradoxus >10 mmHg) are those with a higher risk of progression. Step 3: Score the imaging: Overt diagnostic signs of a large and worsening pericardial effusion (e.g., cardiomegaly on chest x-ray, large pericardial effusion >20 mm on echocardiography with inferior vena cava plethora and right ventricular and left atrial collapse) warrant immediate action.
References 1.
2.
3.
Imazio M, Mayosi BM, Brucato A, et al. Triage and management of pericardial effusion. J Cardiovasc Med (Hagerstown) 2010;11:928-35 Shabetai R. Pericardial effusion: haemodynamic spectrum. Heart 2004;90: 255-6
doi: 10.1586/14779072.2015.1007127
4.
A total score ‡6 indicates the need for urgent pericardiocentesis in the absence of contraindications (i.e., high INR >1.5, severe thrombocytopenia with a platelet count
