Pericardial effusion and tamponade — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 64-year-old woman with metastatic lung cancer has 1 week of worsening dyspnoea and orthopnoea. Her blood pressure is 86/60 mmHg with tachycardia, her jugular venous pressure is elevated and her heart sounds are quiet. Pulsus paradoxus measures 16 mmHg.^[1] Echocardiography shows a circumferential pericardial effusion of 24 mm at end-diastole, with diastolic right atrial collapse lasting more than 0.34 of the cardiac cycle.^[1] The inferior vena cava is plethoric (dilated over 20 mm with less than 50% respiratory reduction in diameter), with dilated hepatic veins.^[1]

1. Define cardiac tamponade as ESC 2025 does, and explain the mechanism of pulsus paradoxus. (2)^[1]
2. Grade her effusion, and give the ESC 2025 Table 17 sensitivity and specificity of the two echocardiographic signs described. (2)^[1]
3. Name four ESC 2025 Figure 12 triage items present here with their points, and state the rule for immediate pericardiocentesis. (2)^[1]
4. What should be avoided, and what can help, while she waits for urgent pericardiocentesis? (2)^[1]
5. Give two ESC 2025 recommendations, with class and level, for her suspected neoplastic effusion. (2)^[1]

Model answers — SAQ 1

1. ESC 2025: a pericardial syndrome occurring when the effusion impairs diastolic filling of the heart until cardiac output is reduced (1 mark).^[1] Pulsus paradoxus, an inspiratory fall in systolic pressure of at least 10 mmHg, is due to exaggerated ventricular interdependence: the overall ventricular volume cannot expand, so a volume change on one side causes the opposite change on the other (1 mark).^[1]
2. Large: ESC 2025 Table 10 grades mild under 10 mm, moderate 10–20 mm and large over 20 mm (maximal end-diastolic diameter) (1 mark).^[1] Diastolic right atrial collapse lasting more than 0.34 of the cardiac cycle length: sensitivity above 90%, specificity 100%; inferior vena cava plethora (dilatation over 20 mm with less than 50% respiratory reduction in diameter, as well as hepatic vein dilatation): sensitivity 97%, specificity 40% (Table 17) (1 mark).^[1]
3. Any four of: malignant disease 2; orthopnoea 3; dyspnoea or tachypnoea 1; pulsus paradoxus (over 10 mmHg) 2; circumferential large effusion (large: over 20 mm) 3; right atrial collapse 1 (Figure 12) (1 mark).^[1] Hypotension (central blood pressure under 95 mmHg) 0.5 and inferior vena cava dilated, not collapsible 1.5 are not credited, because the scenario gives neither a central blood pressure nor a non-collapsible inferior vena cava.^[1] Progressive sinus tachycardia 1 and rapid worsening of symptoms 2 are not credited either, because the scenario describes neither progressive sinus tachycardia nor rapid worsening.^[1] Immediate pericardiocentesis should be considered if there are more than 6 points from at least two categories; the criteria are based on expert consensus (1 mark).^[1]
4. Mechanical ventilation with positive airway pressure and diuretic therapy should be avoided (1 mark).^[1] Temporary fluid administration can help to stabilise her while waiting for urgent pericardiocentesis, which should be performed without delay in unstable patients (1 mark).^[1]
5. Pericardiocentesis is recommended for patients with cardiac tamponade to relieve symptoms and establish the diagnosis of malignant pericardial effusion (Class I, Level C) (1 mark).^[1] Extended pericardial drainage (3–6 days) is recommended in suspected or definite neoplastic pericardial effusion to prevent effusion recurrence (Class I, Level B); also accepted: cytological analysis of pericardial fluid is recommended in neoplastic pericarditis to confirm malignant pericardial disease (Class I, Level C) (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 46-year-old man has a pericardial effusion found incidentally on echocardiography. It is circumferential, measures 23 mm and has been present for 4 months. He has no symptoms, no signs of tamponade, no pericarditis and no systemic disease. C-reactive protein is normal and imaging shows no pericardial inflammation.^[1]

1. Classify his effusion by onset and size under ESC 2025, and state how size is measured. (2)^[1]
2. What first-line assessment does ESC 2025 Figure 19 start with, and which questions does it ask before the size and chronicity question? (2)^[1]
3. Should he receive anti-inflammatory drugs? Give the ESC 2025 reasoning. (2)^[1]
4. How should he be managed and followed now, and what do the conservative-management data show? (2)^[1]
5. A year later he becomes breathless and echocardiography shows haemodynamic impairment. What does ESC 2025 advise, and what does it say about the volume pericardiocentesis should drain? (2)^[1]

Model answers — SAQ 2

1. Chronic (more than 3 months) and large (more than 20 mm), under ESC 2025 Table 10 (1 mark).^[1] Size is the end-diastolic distance of the echo-free space between the epicardium and the parietal pericardium, as the maximal end-diastolic diameter (1 mark).^[1]
2. First-line assessment with history, physical examination, ECG, chest X-ray, transthoracic echocardiography and laboratory assessment (1 mark).^[1] It asks about cardiac tamponade or a symptomatic moderate to large effusion with suspected neoplastic or bacterial aetiology, then concomitant pericarditis, then an associated systemic disease (1 mark).^[1]
3. No: without pericardial inflammation (no CRP elevation and no imaging evidence of inflammation) ESC 2025 does not recommend anti-inflammatory treatment (1 mark).^[1] In chronic effusions with no definite aetiology and no inflammatory markers, empirical anti-inflammatory treatment is futile (1 mark).^[1]
4. Figure 19 sends a large chronic effusion without symptoms to outpatient follow-up; in asymptomatic patients with at least moderate effusions, follow-up every 6 months is reasonable, ideally in specialised centres (1 mark).^[1] ESC 2025 says the usefulness of drainage in asymptomatic or oligosymptomatic, large, chronic, idiopathic effusions without evidence of pericarditis has been revised: conservative treatment improves outcomes, with a tamponade risk of only 2.2% per year without reported deaths (1 mark).^[1]
5. If the effusion becomes symptomatic and echocardiography shows haemodynamic impairment, drainage is warranted (1 mark).^[1] Whenever possible, pericardiocentesis should not drain a large amount of fluid (usually under 500 mL), to prevent pericardial decompression syndrome; a drain can be left and removed when daily drainage is under 30 mL (1 mark).^[1]