nature reviews disease primers https://doi.org/10.1038/s41572-023-00446-1
Primer Check for updates
Cardiac tamponade
Yehuda Adler 1,2 , Arsen D. Ristić 3,4
, Massimo Imazio5, Antonio Brucato6, Sabine Pankuweit 7
, Ivana Burazor ,
4,8
Petar M. Seferović3,4,9 & Jae K. Oh10
Abstract Sections
Cardiac tamponade is a medical emergency caused by the progressive Introduction
accumulation of pericardial fluid (effusion), blood, pus or air in Epidemiology
the pericardium, compressing the heart chambers and leading to Mechanisms/pathophysiology
haemodynamic compromise, circulatory shock, cardiac arrest and
Diagnosis, screening
death. Pericardial diseases of any aetiology as well as complications of and prevention
interventional and surgical procedures or chest trauma can cause cardiac
Management
tamponade. Tamponade can be precipitated in patients with pericardial
Quality of life
effusion by dehydration or exposure to certain medications, particularly
vasodilators or intravenous diuretics. Key clinical findings in patients Outlook
with cardiac tamponade are hypotension, increased jugular venous
pressure and distant heart sounds (Beck triad). Dyspnoea can progress
to orthopnoea (with no rales on lung auscultation) accompanied
by weakness, fatigue, tachycardia and oliguria. In tamponade caused by
acute pericarditis, the patient can experience fever and typical chest pain
increasing on inspiration and radiating to the trapezius ridge. Generally,
cardiac tamponade is a clinical diagnosis that can be confirmed using
various imaging modalities, principally echocardiography. Cardiac
tamponade is preferably resolved by echocardiography-guided
pericardiocentesis. In patients who have recently undergone cardiac
surgery and in those with neoplastic infiltration, effusive–constrictive
pericarditis, or loculated effusions, fluoroscopic guidance can increase
the feasibility and safety of the procedure. Surgical management is
indicated in patients with aortic dissection, chest trauma, bleeding
or purulent infection that cannot be controlled percutaneously. After
pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be
considered to prevent recurrence and effusive–constrictive pericarditis.
A full list of affiliations appears at the end of the paper. e-mail:
Nature Reviews Disease Primers | (2023) 9:36 1
0123456789();:
,Primer
Introduction Epidemiology
The human pericardium is a sac that surrounds the heart and the roots General incidence and prevalence
of the great vessels. The pericardium is comprised of a double-layered To date, few reports have been published on the incidence, prevalence
serosal membrane, with a visceral layer (epicardium) that covers the or exact aetiology of cardiac tamponade in the general population. Only
surface of the heart and a parietal layer that coats the inner surface of indirect data about the epidemiology of conditions that can lead to
the sac. The external surface of the pericardium consists of fibrous cardiac tamponade can be found in the literature. Surprisingly, despite
connective tissue fused to the parietal serosa1. This construction the fairly high frequency of pericardial syndromes in clinical practice
forms the pericardial space, which contains pericardial fluid com- (including acute, incessant, recurrent and chronic pericarditis, pericar-
prised predominantly of plasma filtered through the epicardial capil- dial effusion, cardiac tamponade, and constrictive pericarditis)3, the
laries and probably the parietal layer of the pericardium (Fig. 1a). The incidence or prevalence of these conditions in the general population is
underlying myocardium also contributes a small amount of interstitial unknown and epidemiological data are scarce. However, epidemiologi-
fluid2. Under physiological conditions, the pericardial space contains cal data from national inpatient sample data bases collected between
20–60 ml of fluid drained by the lymphatic capillary bed. The vol- 2008 and 2014 in the USA have been published14. Among 216 million
ume of fluid is determined by the equilibrium between production emergency admissions in patients aged >18 years (mean age ~62 years),
and drainage3. the incidence of cardiac tamponade was 0.05% (115,638 cases); 63.4%
Cardiac tamponade is a potentially life-threatening emergency, of these patients were white, 12.6% were Black and 7.4% were Hispanic.
characterized by progressive intrapericardial accumulation of fluid There was no significant difference in the male-to-female ratio (46.5%
(or pus, blood, clots or air) leading to increased intrapericardial female). The reported causes of cardiac tamponade included chest
pressure and compression of the heart. Diastolic filling and cardiac trauma (2.1%), connective tissue diseases (4.0%), chronic kidney disease
output are subsequently impaired, resulting in haemodynamic (18.4%), cancer (17.0%), sepsis (10.6%) and idiopathic pericarditis (3.7%).
compromise, typical obstructive circulatory shock4 or even cardiac In-hospital mortality was high (14.3%) and remained so throughout the
arrest5,6 (Fig. 1b). study period. Chest trauma, acute kidney injury, metastatic cancer and
Pericardial diseases of any aetiology can cause cardiac tamponade sepsis were significant predictors of mortality14. A post-mortem study
but certain entities have a higher risk of evolution towards circula- focused on haemopericardium found that, among 430,000 postmor-
tory shock (especially tuberculous pericarditis and malignancies)6–9 tems between 1995 and 2004 in a rural English population, mortality
(Table 1). Depending on the aetiology, pericarditis (inflammation of was due to cardiac tamponade in 461 cases15.
the pericardial sac, which can be caused by a bacterial or viral infection,
chest injury, medications or concomitant conditions) is often initially Risk factors
associated with a small pericardial effusion (accumulation of excess Risk factors for cardiac tamponade include pericarditis, malignancies,
fluid in the pericardium) that can increase over time and progress to autoimmune conditions (systemic lupus erythematosus (SLE) and
cardiac tamponade. In patients with massive intrapericardial bleed- rheumatoid arthritis), cardiovascular conditions and iatrogenic (result-
ing (for example, as a consequence of myocardial or coronary artery ing from medical activity such as a treatment or diagnostic procedure)
perforation, extension of aortic dissection, or trauma), acute car- factors such as cardiovascular interventional procedures and surgery.
diac tamponade develops in minutes and is characterized by rapidly
evolving, dramatic clinical haemodynamic deterioration leading to Pericarditis. The most commonly encountered pericardial disease in
cardiac arrest10,11 (Fig. 2a). Pericardial effusion in individuals with the clinic is acute pericarditis, which is the cause of 0.1% of all hospital
severe pulmonary hypertension is a unique, albeit important, subset admissions and 5% of emergency room admissions for chest pain in the
that can be difficult to manage as pericardiocentesis in these individu- USA and Europe3. The reported annual incidence of acute pericarditis
als carries the risk of acute right ventricle failure and can be fatal12. was 27.7 cases per 100,000 of the population in emergency room and
If pericardial effusion occurs slowly, with clinical worsening over hospital admissions from an Italian community16 but was much lower
several days or weeks (Fig. 2b), the compressive effects should be con- in the Finnish national registry for the years 2000–2009 (3.32 cases
sidered as a continuum, with no simple threshold to identify patients per 100,000 of the population)17. These data from Finland only include
in critical condition requiring immediate pericardial drainage9,13, and hospitalized patients and might therefore represent only a minority of
these patients need to be closely monitored to determine if and when cases as many patients with pericarditis are not admitted to hospital.
intervention is needed. Among individuals aged 16–65 years, the risk of pericarditis was higher
In this Primer, we discuss the epidemiology and pathophysiol- in men than in women (relative risk 2.02), and the highest risk difference
ogy of cardiac tamponade as well as the clinical signs and imaging compared with the overall population was among young adults17. In a
features used in diagnosis. This information is based on the 2014 study of 7 million individuals from Danish medical data bases, a much
triage strategy position statement5 and the latest (2015) guidelines higher annual incidence of acute pericarditis was reported (168 cases
on pericardial diseases from the European Society of Cardiology per 100,000 of the population)18. In this investigation, all patients with
(ESC) Working Group on Myocardial and Pericardial Diseases 3 a first-time diagnosis of acute pericarditis during the period 1994–2013
for the diagnosis, scoring and treatment of cardiac tamponade. were identified. Pericarditis was recorded as the primary discharge
We also suggest the best management options for the evacuation diagnosis in 79% of patients. The presence of or progression to cardiac
of pericardial fluid as well as novel strategies for the prevention of tamponade was not evaluated18. This study is more representative that
recurrence. In addition, we discuss patient quality of life in vari- the Italian and Finnish studies as it was not limited to hospital admis-
ous clinical settings. Finally, we highlight gaps in our knowledge sions. A study from the USA revealed that the hospitalization rate
of cardiac tamponade and consider the importance of future stud- in Medicare beneficiaries aged ≥65 years with a principal discharge
ies, clinical trials and registries in addressing important research diagnosis of pericarditis between 1999 and 2012 remained stable dur-
questions. ing the study period (26 per 100,000 person-years)19. The incidence
Nature Reviews Disease Primers | (2023) 9:36 2
0123456789();:
, Primer
a Normal heart Cardiac tamponade
Fibrous pericardium Pericardial sac
filled with fluid
Parietal layer of
serous pericardium
Pericardial cavity
Visceral layer of
serous pericardium
(epicardium)
Myocardium
Endocardium
b
Pulsus paradoxus
Intrathoracic pressure Expiration
Inspiration Inspiration
Ventricular Left
interdependence ventricle
Right
Septum
ventricle
Pericardial
effusion
Ventricular wall collapse Improvement in cardiac Ventricular wall collapse
during inspiration output during expiration during inspiration
Fig. 1 | Anatomical changes to the heart during cardiac tamponade. arrest. Owing to ventricular interdependence, expansion of the right ventricle
a, Schematic of the heart depicting the layers of the pericardium and excessive during inspiration compresses the left ventricle, resulting in decreased filling
intrapericardial pressure during cardiac tamponade. b, The basic pathogenetic and a drop in stroke volume with a decrease in systolic blood pressure (pulsus
mechanisms of cardiac tamponade. Progressive intrapericardial accumulation paradoxus). During expiration, the left ventricle is filled by the restoration of
of fluid leads to increased intrapericardial pressure and compression of the pulmonary venous return but the right ventricle is compressed and systemic
heart. Diastolic filling and cardiac output are subsequently impaired, resulting venous return is interrupted. Part b adapted with permission from ref. 207,
in haemodynamic compromise, circulatory shock and, eventually, cardiac © The Authors.
of pericarditis in this study is similar to that reported by the Italian between 26 (refs. 16,19) and 168 (ref. 17) cases per 100,000 of the popu-
group15 and was consistently higher in men and in very elderly patients lation, the question remains about what proportion of these patients
(≥85 years of age)19. Adjusted all-cause mortality decreased over the develop pericardial effusion and cardiac tamponade.
study period (from 7.6% in 1999 to 5.7% in 2012 for 30-day mortality, and The incidence of pericardial effusion is estimated to be around
from 19.7% in 1999 to 17.3% in 2011 for 1-year mortality)19. On the basis 20 cases per 100,000 population20. Pericardial effusion in developed
of these studies, assuming an annual incidence of acute pericarditis of countries is most frequently of idiopathic origin (up to 50% of cases),
Nature Reviews Disease Primers | (2023) 9:36 3
0123456789();:
Primer Check for updates
Cardiac tamponade
Yehuda Adler 1,2 , Arsen D. Ristić 3,4
, Massimo Imazio5, Antonio Brucato6, Sabine Pankuweit 7
, Ivana Burazor ,
4,8
Petar M. Seferović3,4,9 & Jae K. Oh10
Abstract Sections
Cardiac tamponade is a medical emergency caused by the progressive Introduction
accumulation of pericardial fluid (effusion), blood, pus or air in Epidemiology
the pericardium, compressing the heart chambers and leading to Mechanisms/pathophysiology
haemodynamic compromise, circulatory shock, cardiac arrest and
Diagnosis, screening
death. Pericardial diseases of any aetiology as well as complications of and prevention
interventional and surgical procedures or chest trauma can cause cardiac
Management
tamponade. Tamponade can be precipitated in patients with pericardial
Quality of life
effusion by dehydration or exposure to certain medications, particularly
vasodilators or intravenous diuretics. Key clinical findings in patients Outlook
with cardiac tamponade are hypotension, increased jugular venous
pressure and distant heart sounds (Beck triad). Dyspnoea can progress
to orthopnoea (with no rales on lung auscultation) accompanied
by weakness, fatigue, tachycardia and oliguria. In tamponade caused by
acute pericarditis, the patient can experience fever and typical chest pain
increasing on inspiration and radiating to the trapezius ridge. Generally,
cardiac tamponade is a clinical diagnosis that can be confirmed using
various imaging modalities, principally echocardiography. Cardiac
tamponade is preferably resolved by echocardiography-guided
pericardiocentesis. In patients who have recently undergone cardiac
surgery and in those with neoplastic infiltration, effusive–constrictive
pericarditis, or loculated effusions, fluoroscopic guidance can increase
the feasibility and safety of the procedure. Surgical management is
indicated in patients with aortic dissection, chest trauma, bleeding
or purulent infection that cannot be controlled percutaneously. After
pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be
considered to prevent recurrence and effusive–constrictive pericarditis.
A full list of affiliations appears at the end of the paper. e-mail:
Nature Reviews Disease Primers | (2023) 9:36 1
0123456789();:
,Primer
Introduction Epidemiology
The human pericardium is a sac that surrounds the heart and the roots General incidence and prevalence
of the great vessels. The pericardium is comprised of a double-layered To date, few reports have been published on the incidence, prevalence
serosal membrane, with a visceral layer (epicardium) that covers the or exact aetiology of cardiac tamponade in the general population. Only
surface of the heart and a parietal layer that coats the inner surface of indirect data about the epidemiology of conditions that can lead to
the sac. The external surface of the pericardium consists of fibrous cardiac tamponade can be found in the literature. Surprisingly, despite
connective tissue fused to the parietal serosa1. This construction the fairly high frequency of pericardial syndromes in clinical practice
forms the pericardial space, which contains pericardial fluid com- (including acute, incessant, recurrent and chronic pericarditis, pericar-
prised predominantly of plasma filtered through the epicardial capil- dial effusion, cardiac tamponade, and constrictive pericarditis)3, the
laries and probably the parietal layer of the pericardium (Fig. 1a). The incidence or prevalence of these conditions in the general population is
underlying myocardium also contributes a small amount of interstitial unknown and epidemiological data are scarce. However, epidemiologi-
fluid2. Under physiological conditions, the pericardial space contains cal data from national inpatient sample data bases collected between
20–60 ml of fluid drained by the lymphatic capillary bed. The vol- 2008 and 2014 in the USA have been published14. Among 216 million
ume of fluid is determined by the equilibrium between production emergency admissions in patients aged >18 years (mean age ~62 years),
and drainage3. the incidence of cardiac tamponade was 0.05% (115,638 cases); 63.4%
Cardiac tamponade is a potentially life-threatening emergency, of these patients were white, 12.6% were Black and 7.4% were Hispanic.
characterized by progressive intrapericardial accumulation of fluid There was no significant difference in the male-to-female ratio (46.5%
(or pus, blood, clots or air) leading to increased intrapericardial female). The reported causes of cardiac tamponade included chest
pressure and compression of the heart. Diastolic filling and cardiac trauma (2.1%), connective tissue diseases (4.0%), chronic kidney disease
output are subsequently impaired, resulting in haemodynamic (18.4%), cancer (17.0%), sepsis (10.6%) and idiopathic pericarditis (3.7%).
compromise, typical obstructive circulatory shock4 or even cardiac In-hospital mortality was high (14.3%) and remained so throughout the
arrest5,6 (Fig. 1b). study period. Chest trauma, acute kidney injury, metastatic cancer and
Pericardial diseases of any aetiology can cause cardiac tamponade sepsis were significant predictors of mortality14. A post-mortem study
but certain entities have a higher risk of evolution towards circula- focused on haemopericardium found that, among 430,000 postmor-
tory shock (especially tuberculous pericarditis and malignancies)6–9 tems between 1995 and 2004 in a rural English population, mortality
(Table 1). Depending on the aetiology, pericarditis (inflammation of was due to cardiac tamponade in 461 cases15.
the pericardial sac, which can be caused by a bacterial or viral infection,
chest injury, medications or concomitant conditions) is often initially Risk factors
associated with a small pericardial effusion (accumulation of excess Risk factors for cardiac tamponade include pericarditis, malignancies,
fluid in the pericardium) that can increase over time and progress to autoimmune conditions (systemic lupus erythematosus (SLE) and
cardiac tamponade. In patients with massive intrapericardial bleed- rheumatoid arthritis), cardiovascular conditions and iatrogenic (result-
ing (for example, as a consequence of myocardial or coronary artery ing from medical activity such as a treatment or diagnostic procedure)
perforation, extension of aortic dissection, or trauma), acute car- factors such as cardiovascular interventional procedures and surgery.
diac tamponade develops in minutes and is characterized by rapidly
evolving, dramatic clinical haemodynamic deterioration leading to Pericarditis. The most commonly encountered pericardial disease in
cardiac arrest10,11 (Fig. 2a). Pericardial effusion in individuals with the clinic is acute pericarditis, which is the cause of 0.1% of all hospital
severe pulmonary hypertension is a unique, albeit important, subset admissions and 5% of emergency room admissions for chest pain in the
that can be difficult to manage as pericardiocentesis in these individu- USA and Europe3. The reported annual incidence of acute pericarditis
als carries the risk of acute right ventricle failure and can be fatal12. was 27.7 cases per 100,000 of the population in emergency room and
If pericardial effusion occurs slowly, with clinical worsening over hospital admissions from an Italian community16 but was much lower
several days or weeks (Fig. 2b), the compressive effects should be con- in the Finnish national registry for the years 2000–2009 (3.32 cases
sidered as a continuum, with no simple threshold to identify patients per 100,000 of the population)17. These data from Finland only include
in critical condition requiring immediate pericardial drainage9,13, and hospitalized patients and might therefore represent only a minority of
these patients need to be closely monitored to determine if and when cases as many patients with pericarditis are not admitted to hospital.
intervention is needed. Among individuals aged 16–65 years, the risk of pericarditis was higher
In this Primer, we discuss the epidemiology and pathophysiol- in men than in women (relative risk 2.02), and the highest risk difference
ogy of cardiac tamponade as well as the clinical signs and imaging compared with the overall population was among young adults17. In a
features used in diagnosis. This information is based on the 2014 study of 7 million individuals from Danish medical data bases, a much
triage strategy position statement5 and the latest (2015) guidelines higher annual incidence of acute pericarditis was reported (168 cases
on pericardial diseases from the European Society of Cardiology per 100,000 of the population)18. In this investigation, all patients with
(ESC) Working Group on Myocardial and Pericardial Diseases 3 a first-time diagnosis of acute pericarditis during the period 1994–2013
for the diagnosis, scoring and treatment of cardiac tamponade. were identified. Pericarditis was recorded as the primary discharge
We also suggest the best management options for the evacuation diagnosis in 79% of patients. The presence of or progression to cardiac
of pericardial fluid as well as novel strategies for the prevention of tamponade was not evaluated18. This study is more representative that
recurrence. In addition, we discuss patient quality of life in vari- the Italian and Finnish studies as it was not limited to hospital admis-
ous clinical settings. Finally, we highlight gaps in our knowledge sions. A study from the USA revealed that the hospitalization rate
of cardiac tamponade and consider the importance of future stud- in Medicare beneficiaries aged ≥65 years with a principal discharge
ies, clinical trials and registries in addressing important research diagnosis of pericarditis between 1999 and 2012 remained stable dur-
questions. ing the study period (26 per 100,000 person-years)19. The incidence
Nature Reviews Disease Primers | (2023) 9:36 2
0123456789();:
, Primer
a Normal heart Cardiac tamponade
Fibrous pericardium Pericardial sac
filled with fluid
Parietal layer of
serous pericardium
Pericardial cavity
Visceral layer of
serous pericardium
(epicardium)
Myocardium
Endocardium
b
Pulsus paradoxus
Intrathoracic pressure Expiration
Inspiration Inspiration
Ventricular Left
interdependence ventricle
Right
Septum
ventricle
Pericardial
effusion
Ventricular wall collapse Improvement in cardiac Ventricular wall collapse
during inspiration output during expiration during inspiration
Fig. 1 | Anatomical changes to the heart during cardiac tamponade. arrest. Owing to ventricular interdependence, expansion of the right ventricle
a, Schematic of the heart depicting the layers of the pericardium and excessive during inspiration compresses the left ventricle, resulting in decreased filling
intrapericardial pressure during cardiac tamponade. b, The basic pathogenetic and a drop in stroke volume with a decrease in systolic blood pressure (pulsus
mechanisms of cardiac tamponade. Progressive intrapericardial accumulation paradoxus). During expiration, the left ventricle is filled by the restoration of
of fluid leads to increased intrapericardial pressure and compression of the pulmonary venous return but the right ventricle is compressed and systemic
heart. Diastolic filling and cardiac output are subsequently impaired, resulting venous return is interrupted. Part b adapted with permission from ref. 207,
in haemodynamic compromise, circulatory shock and, eventually, cardiac © The Authors.
of pericarditis in this study is similar to that reported by the Italian between 26 (refs. 16,19) and 168 (ref. 17) cases per 100,000 of the popu-
group15 and was consistently higher in men and in very elderly patients lation, the question remains about what proportion of these patients
(≥85 years of age)19. Adjusted all-cause mortality decreased over the develop pericardial effusion and cardiac tamponade.
study period (from 7.6% in 1999 to 5.7% in 2012 for 30-day mortality, and The incidence of pericardial effusion is estimated to be around
from 19.7% in 1999 to 17.3% in 2011 for 1-year mortality)19. On the basis 20 cases per 100,000 population20. Pericardial effusion in developed
of these studies, assuming an annual incidence of acute pericarditis of countries is most frequently of idiopathic origin (up to 50% of cases),
Nature Reviews Disease Primers | (2023) 9:36 3
0123456789();:
