Cardio · pericardial-myocardial-other
Pericardial effusion and tamponade physiology
Fellowship-level guide to pericardial effusion and cardiac tamponade under the 2025 ESC myocarditis and pericarditis guideline, with the 2015 ESC pericardial guideline as history and the 2024 ESC and 2022 ACC/AHA aortic guidelines for tamponade in aortic dissection: effusion classification and grading, causes, the physiology of tamponade, Beck triad and pulsus paradoxus, the echocardiographic signs, the Figure 19 effusion triage and the Figure 12 tamponade triage score, pericardiocentesis and surgical drainage with their class and level, malignant, tuberculous, purulent and post-operative effusions, and Australian population data.
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Red flags
- ESC 2025: pericardiocentesis (echocardiography-, CT- or fluoroscopy-guided) is recommended for cardiac tamponade, suspected bacterial or neoplastic pericarditis, or symptomatic moderate to large pericardial effusion despite medical therapy (Class I, Level C)
- In tamponade, positive airway pressure ventilation and diuretic therapy should be avoided; temporary fluid can help to stabilise the patient while waiting for urgent pericardiocentesis (ESC 2025)
- Beck triad (hypotension, increased JVP, quiet heart sounds) may be lacking in medical tamponade with slowly accumulating fluid (ESC 2025)
- An effusion without raised inflammatory markers carries an increased risk of a neoplastic aetiology (likelihood ratio 2.9) (ESC 2025)
This page covers pericardial effusion and cardiac tamponade: how effusions are graded and triaged, why tamponade develops, how it is recognised, and when and how the fluid is drained. ESC 2025 calls tamponade and constrictive pericarditis the two most serious complications of pericarditis; the diagnosis and drug treatment of pericarditis itself are covered in the acute pericarditis topic.[1]
- Related topic: Acute pericarditis.
- Related topic: Aortic dissection type A and B.
Overview and definitions
Start with the normal sac.[1] ESC 2025 says it contains 10–50 mL of fluid, a plasma ultrafiltrate that lubricates the pericardial layers.[1]
Fluid can build up in several ways.[1] Any process that inflames the pericardium increases the fluid and produces an exudate.[1] ESC 2025 adds two other mechanisms: decreased reabsorption when systemic venous pressure rises, as in congestive heart failure (HF) or pulmonary hypertension (a transudate), and decreased lymphatic drainage.[1]
Tamponade is what happens when that fluid starts to win.[1] ESC 2025 defines cardiac tamponade as a pericardial syndrome occurring when the effusion impairs diastolic filling of the heart until cardiac output is reduced.[1] In pericarditis, tamponade is a life-threatening condition in which inflammation leads to the accumulation of compressive pericardial fluid.[1]
Classification of pericardial effusion (ESC 2025, Table 10)
| Feature | ESC 2025 categories |
|---|---|
| Onset | Acute (≤4 weeks); subacute (>4 weeks to ≤3 months); chronic (>3 months) |
| Size (maximal end-diastolic diameter) | Mild <10 mm; moderate 10–20 mm; large >20 mm |
| Distribution | Circumferential or loculated |
| Composition | Transudate or exudate |
ESC 2025 measures size as the end-diastolic distance of the echo-free space between the epicardium and the parietal pericardium.[1] It recommends that images include the extent and location of each effusion measurement, as this allows follow-up studies.[1] The semiquantitative size helps to estimate the risk of a non-idiopathic aetiology and of complications.[1]
[1]Epidemiology and causes
Many effusions are found by accident.[1] ESC 2025 says a significant proportion of patients are asymptomatic and the effusion is an incidental finding on routine examination.[1] An effusion is often associated with a known or unknown medical condition, such as hypothyroidism, in up to 60% of cases, especially if moderate or large.[1]
The causes depend on where you work.[1] ESC 2025 summarises six major surveys from the past three decades of moderate to large effusions.[1] In developed countries many remain idiopathic (up to 50%); other causes include cancer (10%–32%), infections (15%–30%), iatrogenic causes (15%–20%) and connective tissue diseases (5%–15%).[1] In developing countries where tuberculosis (TB) is endemic, TB is the dominant cause (over 60%).[1]
Causes of cardiac tamponade (ESC 2025, Table 8)
| Group (in order of relative frequency) | Causes |
|---|---|
| Common | Neoplasm or malignancy; iatrogenic or trauma; pericarditis; tuberculosis (most common in developing countries) |
| Less common | Collagen vascular diseases (systemic lupus erythematosus, rheumatoid arthritis, scleroderma); pericardial injury syndrome; acute myocardial infarction; aortic dissection; uraemia; bacterial infection; pneumopericardium |
ESC 2025 says tamponade shares the causes of effusion.[1] In clinical practice the most common include cancer, TB, purulent infections, trauma, iatrogenic complications of cardiovascular interventions (such as arrhythmia ablation, device implantation and post-cardiac injury syndrome), acute aortic disease, systemic inflammatory diseases and renal failure.[1] After viral or idiopathic acute pericarditis tamponade is rare (1%–2% of cases); with a non-idiopathic aetiology it is more common (20%).[1]
[1]Pathophysiology
How fast the fluid collects matters as well as how much.[1] ESC 2025 explains that the pericardium is relatively stiff.[1] When fluid collects quickly, as in haemopericardium, the limit of stretch is reached with only 200–300 mL.[1] A slowly accumulating effusion may reach 1 to 2 L before tamponade develops.[1]
ESC 2025 calls tamponade a last-drop phenomenon.[1] A small increase in pericardial volume may precipitate the syndrome, and aspirating a small amount of fluid may greatly improve the patient.[1] The size and distribution of the effusion may vary.[1] Effusions are usually circumferential, but after trauma or cardiac surgery they may be loculated and cause localised compression and tamponade.[1]
ESC 2025 lists what sets the severity.[1] The clinical and haemodynamic abnormalities depend on the amount of fluid and its rate of accumulation, the distensibility of the pericardium, and the compliance and filling pressures of the cardiac chambers.[1]
Pulsus paradoxus comes from exaggerated ventricular interdependence.[1] ESC 2025 explains that in tamponade the overall volume of the ventricles cannot expand, so any change in volume on one side of the heart causes the opposite change on the other.[1] On ECG the patient usually shows tachycardia, low QRS voltages and electrical alternans, due to the damping effect of the fluid and the swinging heart.[1]
[1]Clinical presentation
Effusion
ESC 2025 says the presentation of an effusion depends on how fast the fluid accumulates.[1] Classic symptoms include exertional dyspnoea progressing to orthopnoea, chest pain and a feeling of fullness.[1]
- Nausea: compression of the diaphragm.[1]
- Dysphagia: compression of the oesophagus.[1]
- Hoarseness: compression of the recurrent laryngeal nerve.[1]
- Hiccups: compression of the phrenic nerve.[1]
Without haemodynamic compromise, physical examination may be normal (ESC 2025).[1] In acute pericarditis, a friction rub heard in up to one-third of cases could disappear once an effusion is present.[1]
Tamponade
Beck described a triad of hypotension, increased jugular venous pressure (JVP) and quiet heart sounds.[1] It was classically identified in surgical tamponade: acute tamponade from intrapericardial haemorrhage after trauma or myocardial or aortic rupture.[1] ESC 2025 warns that the triad may be lacking in medical tamponade with slowly accumulating fluid.[1]
Surgical tamponade
ESC 2025
- Acute tamponade from intrapericardial haemorrhage after trauma, or myocardial or aortic rupture
- Beck triad was classically identified in this setting
Medical tamponade
ESC 2025
- Slowly accumulating pericardial fluid
- Beck triad may be lacking
Blood pressure depends on the tempo.[1] ESC 2025 says acute tamponade is usually associated with tachycardia and low blood pressure (under 90 mmHg), while in subacute or chronic tamponade the pressure is only slightly reduced.[1]
ESC 2025 defines pulsus paradoxus as an inspiratory fall in systolic blood pressure of at least 10 mmHg.[1] On examination, classical signs include neck vein distension with elevated JVP, pulsus paradoxus and diminished heart sounds.[1]
ESC 2025 also describes pericarditis with tamponade, a life-threatening condition in which inflammation of the pericardium leads to the accumulation of compressive pericardial fluid.[1] In that setting, symptoms may include chest discomfort, fatigue and dyspnoea.[1] Clinical signs include hypotension, tachycardia, raised JVP, pulsus paradoxus, muffled heart sounds, electrical alternans with decreased ECG voltage, and an enlarged cardiac silhouette on chest X-ray.[1]
Differential diagnosis
The key alternative is a constrictive process hiding under the fluid.[1] ESC 2025 says effusive–constrictive pericarditis occurs when constrictive physiology is uncovered after drainage of an effusion with tamponade.[1] In patients who seem to have uncomplicated tamponade, the diagnosis usually becomes evident during pericardiocentesis.[1]
Effusive–constrictive pericarditis (ESC 2025, Table 18, effusive–constrictive row)
| Syndrome | Definition | Therapy |
|---|---|---|
| Effusive–constrictive pericarditis (differential diagnosis: cardiac tamponade, constrictive pericarditis) | Failure of the right atrial pressure to fall by 50% or to a level <10 mmHg after pericardiocentesis; may also be diagnosed by non-invasive imaging | Pericardiocentesis followed by medical therapy; surgery for persistent cases |
ESC 2025 gives the exact haemodynamic definition: right atrial pressure failing to fall by 50% or more, or to below 10 mmHg, despite intrapericardial pressure being lowered to near 0 mmHg by pericardiocentesis.[1] Current multimodality imaging allows a clinical diagnosis of effusive–constrictive pericarditis without cardiac catheterisation.[1] A persistently raised right atrial pressure after effective pericardiocentesis may also come from tricuspid regurgitation or right heart failure.[1]
Two more distinctions shape the work-up.[1] ESC 2025 says effusive pericarditis (50%–60% of pericarditis cases) has an effusion by definition, and a moderate to large effusion is more often non-idiopathic.[1] An effusion without raised inflammatory markers carries an increased risk of a neoplastic cause (likelihood ratio 2.9).[1]
Clinical and bedside assessment
ESC 2025: complete clinical evaluation, including history, physical examination, chest X-ray, biomarkers, ECG and echocardiography, is recommended in all patients with suspected myocarditis and/or pericarditis for the initial diagnostic assessment (Class I, Level C).[1] Its basic physical examination includes clinical stability and clinical symptoms or signs of tamponade.[1]
- Pulse and pressure: in acute tamponade, usually tachycardia and a blood pressure under 90 mmHg; in subacute or chronic tamponade the pressure is only slightly reduced (ESC 2025).[1]
- Pulsus paradoxus: an inspiratory fall in systolic pressure of at least 10 mmHg (ESC 2025).[1]
- Neck veins and heart sounds: distended neck veins with elevated JVP, and diminished heart sounds (ESC 2025).[1]
- ECG: usually tachycardia, low QRS voltages and electrical alternans (ESC 2025).[1]
Investigations
Echocardiography
ESC 2025 calls echocardiography the primary tool for diagnosis, sizing, assessment of haemodynamic effects and follow-up.[1] Transthoracic echocardiography can detect an effusion and assess its haemodynamic importance and any constrictive physiology.[1] It enables recognition of tamponade and of constriction.[1]
Echocardiographic signs of cardiac tamponade (ESC 2025, Table 17; n.a., not available)
| Echocardiographic feature | Sensitivity | Specificity |
|---|---|---|
| Large pericardial effusion with swinging heart | n.a. | n.a. |
| Diastolic collapse of the right atrium | 50%–100% | 33%–100% |
| Duration of right atrial diastolic collapse as a ratio of the cardiac cycle length >0.34 | >90% | 100% |
| Diastolic collapse of the right ventricle | 48%–100% | 72%–100% |
| Respiratory changes of mitral E velocity >25%–30%, tricuspid E velocity >40%–60% | n.a. | n.a. |
| Inferior vena cava plethora (dilatation >20 mm and <50% reduction of diameter with respiratory phases), as well as hepatic vein dilatation | 97% | 40% |
Read the table as a teacher would.[1] Inferior vena cava plethora is sensitive (97%) but has a specificity of only 40%.[1] Diastolic collapse of the right atrium lasting more than 0.34 of the cardiac cycle length is listed with a sensitivity above 90% and a specificity of 100%.[1]
[1]ECG and chest X-ray
ESC 2025 says QRS amplitude can fall in acute pericarditis and/or acute myocarditis, especially with large effusions or extensive myocardial injury.[1] Electrical alternans of the QRS complexes has been attributed to the heart swinging within a large effusion.[1] An enlarged cardiac silhouette on chest X-ray is listed among the clinical signs of pericarditis with tamponade.[1]
CT, CMR and laboratory tests
Advanced imaging (CT and cardiovascular magnetic resonance, CMR) gives information on local inflammation, masses, chest abnormalities such as pectus excavatum, loculated effusions and systemic diseases (ESC 2025).[1] Contrast-enhanced CT may be very useful for the aetiological diagnosis of a large effusion, including tamponade.[1] ESC 2025: CT is recommended to evaluate pericardial thickness, calcifications, masses and loculated pericardial effusions, as well as concomitant pleuropulmonary diseases and chest abnormalities (Class I, Level C).[1]
- C-reactive protein (CRP) before the needle: ESC 2025 says CRP should be measured before pericardiocentesis, because it can increase after the procedure.[1]
- No inflammation, think cancer: an effusion without raised inflammatory markers carries an increased risk of a neoplastic aetiology (likelihood ratio 2.9); in a worsening large effusion without systemic inflammation, cancer should be excluded with advanced imaging, mainly CT (ESC 2025).[1]
- Light criteria do not apply: ESC 2025 says the pleural-fluid Light criteria should not be used for pericardial fluid, because pericardial fluid is rich in mesothelial cells, proteins, albumin and lactate dehydrogenase, so many fluids would be misclassified as exudates.[1]
- Fluid and tissue: percutaneous access may also provide fluid for pathological and pathogen examinations (bacterial or viral aetiology) and pericardial or epicardial biopsies, particularly in cancer screening (ESC 2025).[1]
- Purulent versus tuberculous versus neoplastic fluid: a low pericardial-to-serum glucose ratio (mean 0.3) and a high white cell count with 92% neutrophils (mean 2.8/mL) separate purulent from tuberculous (ratio 0.7, 1.7/mL, 50% neutrophils) and neoplastic fluid (ratio 0.8, 3.3/mL, 55% neutrophils) (ESC 2025).[1]
ESC 2025: pericardial or epicardial biopsy may be considered in relapsing pericardial effusion as part of the diagnostic work-up when the diagnosis cannot be reached with multimodality imaging and laboratory examinations (Class IIb, Level C).[1]
Triage and management of pericardial effusion
ESC 2025 presents a practical routine evaluation for triage in its Figure 19.[1] The figure starts with first-line assessment by history, physical examination, ECG, chest X-ray, transthoracic echocardiography and laboratory tests, then asks a series of yes-or-no questions.[1]
- Tamponade, or a symptomatic moderate to large effusion with suspected neoplastic or bacterial aetiology? Yes: admission, pericardiocentesis and an aetiology search.[1]
- Concomitant pericarditis? Yes: treat as pericarditis.[1]
- Associated systemic disease? Yes: treat the systemic condition.[1]
- Large (>20 mm) and chronic (>3 months) effusion? No: outpatient follow-up. Yes, and asymptomatic: outpatient follow-up.[1]
- Large, chronic and symptomatic? Pericardiocentesis with drainage, then empiric anti-inflammatory therapy.[1]
- Improvement? Yes: outpatient follow-up and treatment according to the specific aetiology. No: is there fluid re-accumulation? If it re-accumulates and is symptomatic, pericardial window; otherwise outpatient follow-up and treatment according to the specific aetiology.[1]
ESC 2025 says the treatment of pericardial effusion is shown in Figure 19.[1] Therapy should be targeted at the aetiology as far as possible.[1] Without pericardial inflammation (no CRP elevation and no imaging evidence of pericardial inflammation), anti-inflammatory treatment is not recommended.[1] In chronic effusions with no definite aetiology and no inflammatory markers, empirical anti-inflammatory treatment is futile.[1]
The large, chronic, idiopathic effusion with few or no symptoms and without evidence of pericarditis is where recent data have revised the role of drainage.[1] ESC 2025 says the usefulness of drainage in asymptomatic or oligosymptomatic, large, chronic, idiopathic effusions without evidence of pericarditis has been revised.[1] Conservative treatment improves outcomes, with a tamponade risk of only 2.2% per year and no reported deaths, and survival after recurrence or complications is significantly better without intervention.[1] If the effusion becomes symptomatic during follow-up and echocardiography shows haemodynamic impairment, drainage is warranted.[1]
[1]Management of tamponade: the first hour
Tamponade is a high-risk diagnosis.[1] ESC 2025 says it identifies patients at increased risk of complications during follow-up and with a high probability of a non-viral aetiology, who should be admitted for therapy and monitoring.[1] Its Table 7 lists signs and symptoms of tamponade, and tamponade on imaging, as high-risk features of pericarditis.[1] ESC 2025: hospital admission is recommended for patients with high-risk pericarditis for monitoring and treatment (Class I, Level B).[1]
How urgent? The ESC 2025 Figure 12 triage score
Not every tamponade needs immediate pericardiocentesis.[1] ESC 2025 says clinical triage has been proposed to indicate urgent management: an overall score above 6 indicates the need for urgent pericardiocentesis, and a lower score suggests delaying the intervention.[1] The Figure 12 legend states the rule: immediate pericardiocentesis should be considered with more than 6 points from at least two categories, using criteria based on expert consensus.[1]
Criteria for triage of patients with pericardial effusion at risk of progression to cardiac tamponade (ESC 2025, Figure 12)
| Aetiology | Points | Clinical presentation | Points | Imaging | Points |
|---|---|---|---|---|---|
| Malignant disease | 2 | Dyspnoea/tachypnoea | 1 | Cardiomegaly on chest X-ray | 1 |
| Tuberculosis | 2 | Orthopnoea | 3 | Electrical alternans on ECG | 0.5 |
| Recent radiotherapy | 1 | Hypotension (central blood pressure <95 mmHg) | 0.5 | Microvoltage on ECG | 1 |
| Recent viral infection | 1 | Progressive sinus tachycardia | 1 | Circumferential large effusion | 3 |
| Recurrent effusion | 1 | Oliguria | 1 | Moderate effusion | 1 |
| Chronic terminal renal failure | 1 | Pulsus paradoxus (>10 mmHg) | 2 | Small effusion | -1 |
| Immunosuppression | 1 | Pericardial chest pain | 0.5 | Right atrial collapse | 1 |
| Dysthyroidism | -1 | Pericardial friction rub | 0.5 | Inferior vena cava dilated, not collapsible | 1.5 |
| Systemic autoimmune disease | -1 | Rapid worsening of symptoms | 2 | Right ventricular collapse | 1.5 |
| Slow disease evolution | -1 | Left atrial collapse | 2 | ||
| Mitral/tricuspid respiratory flow variations | 1 | ||||
| Swinging heart | 1 |
The flowchart in the same figure starts from a definite diagnosis of tamponade.[1] High-risk features lead to pericardiocentesis with drainage; without them, pericardiocentesis is postponed and empiric anti-inflammatory therapy is given.[1] After drainage, improvement leads to outpatient follow-up, and no improvement to a pericardial window.[1]
Two cautions apply.[1][2] The flowchart box prints "cumulative score ≥6", while the legend and the text use more than 6, so quote the legend rule and its two-category condition.[1] The 2015 ESC guideline, now history, said a triage system proposed by the ESC Working Group on Myocardial and Pericardial Diseases was essentially based on expert consensus and required additional validation in order to be recommended in clinical practice.[2]
[1]Pericardiocentesis and surgical drainage
Interventional techniques in pericarditis (ESC 2025, Recommendation Table 12)
| ESC 2025 recommendation (Recommendation Table 12) | Class | Level |
|---|---|---|
| Pericardiocentesis (echocardiography-, CT- or fluoroscopy-guided) for cardiac tamponade, or suspected bacterial or neoplastic pericarditis, or symptomatic moderate to large pericardial effusion despite medical therapy | I | C |
| Surgical pericardial drainage in patients with pericardial effusion when percutaneous pericardiocentesis is not feasible, or with purulent effusion, to allow complete drainage and prevent constriction | I | C |
| Surgical pleuro-pericardial window in patients with relapsing pericardial effusion despite medical therapy | I | C |
Who needs the needle
ESC 2025 says percutaneous pericardiocentesis guided by echocardiography or fluoroscopy is indicated for tamponade and for symptomatic moderate to large effusions not responding to medical therapy.[1] It is also indicated when a search for the aetiological agent is needed, for example with suspected cancer or bacterial infection.[1] The treatment of tamponade is drainage, preferably by needle pericardiocentesis with echocardiographic or fluoroscopic guidance.[1]
How it is done
Percutaneous pericardiocentesis (ESC 2025)
- 1
Image guidance
Imaging is essential: echocardiography, CT or fluoroscopy
- 2
Needle and route
A needle, usually 16–20 gauge, into the sub-xiphoid space; an apical or left-lateral approach might be used
- 3
Volume
Whenever possible, pericardiocentesis should not drain a large amount of fluid (usually under 500 mL), to prevent pericardial decompression syndrome
- 4
Drain
Complete drainage can be achieved by leaving a drain, removed when the daily drainage is under 30 mL
- 5
Catheter time
The catheter should usually remain in situ for a few days, also based on the type and efficacy of concomitant systemic and/or topical drug treatment
Pericardiocentesis should be performed by experienced operators trained or certified in acute cardiovascular care (ESC 2025).[1] Its variable complication risk ranges from 4% to 10%, depending on the type of monitoring, the operator's skill and the setting (emergent, urgent or elective).[1] The most common complications include arrhythmias, coronary artery or cardiac chamber puncture, haemothorax, pneumothorax, pneumopericardium and hepatic injury.[1]
When surgery is better
- Surgical drainage: required when percutaneous pericardiocentesis is not feasible or the effusion is purulent, to allow complete drainage and prevent organisation of the effusion (ESC 2025).[1]
- Surgical approach to tamponade: especially for purulent pericarditis or urgent bleeding into the pericardium (ESC 2025).[1]
- Surgical pericardiocentesis: rarely performed for urgent or emergency conditions, but used for a large effusion needing expeditious drainage that percutaneous drainage cannot achieve, such as purulent fluid or clot aspiration (ESC 2025).[1]
- Pleuro-pericardial window: usually between the lateral or left posterior pericardium and the left pleura; indicated for relapsing effusion with haemodynamic compromise despite conservative treatment or percutaneous drainage (ESC 2025).[1]
- Window route: a small thoracotomy or endoscopy; in selected cases the window can drain into the peritoneal cavity (ESC 2025).[1]
- Balloon pericardiotomy: a percutaneous alternative to the endoscopic or surgical pleuro-pericardial window, especially as palliative and temporary relief; ESC 2025 says it should not be a first- or second-line intervention and reserves it for very rare cases, such as recurrent neoplastic effusion and tamponade, absolute contraindications to surgery, or very poor quality of life in terminal patients.[1]
- Sclerosing agents such as talc: should not be used, because they are less effective than a window or pericardiectomy and risk inducing constriction (ESC 2025).[1]
Specific causes and settings
Malignant effusion
ESC 2025 says neoplastic involvement occasionally presents as pericarditis but more commonly as an isolated effusion, usually moderate to large or with tamponade, with or without masses on imaging.[1] The definitive diagnosis rests on malignant infiltration in pericardial fluid (cytology) or pericardial biopsy.[1] Be careful with the cancer patient: in almost two-thirds of patients with documented malignancy, pericardial involvement has a non-malignant cause.[1] Tumour markers in the fluid may support a probable diagnosis, but none has been proven accurate enough to separate malignant from benign effusions.[1]
Neoplastic pericardial involvement (ESC 2025, Recommendation Table 21)
| ESC 2025 recommendation (Recommendation Table 21) | Class | Level |
|---|---|---|
| Pericardiocentesis for patients with cardiac tamponade, to relieve symptoms and establish the diagnosis of malignant pericardial effusion | I | C |
| Extended pericardial drainage (3–6 days) in patients with suspected or definite neoplastic pericardial effusion, to prevent effusion recurrence | I | B |
| Cytological analysis of pericardial fluid in neoplastic pericarditis, to confirm malignant pericardial disease | I | C |
| Systemic antineoplastic treatment in confirmed neoplastic aetiology, to treat the primary and secondary metastatic involvement | I | C |
| Pericardiocentesis in moderate to large effusion, to establish the diagnosis of malignant effusion when multimodality imaging cannot | IIa | C |
| Pericardial or epicardial biopsy in suspected malignant pericardial disease when multimodality imaging or cytology cannot reach the diagnosis, to confirm the diagnosis | IIb | C |
| Intrapericardial therapy, in agreement with the oncologist, in cases refractory to systemic antineoplastic treatment | IIb | C |
Malignant effusions recur in more than half of cases (ESC 2025).[1] Extended pericardial drainage can be necessary to prevent effusion recurrence and to provide a route for intrapericardial therapy.[1] For recurrent effusions, additional interventions may include pericardiotomy, a pericardial window and percutaneous balloon pericardiotomy; all are palliative, aimed at improving quality of life in patients with a poor short-term outcome.[1] Through an intrapericardial catheter placed after drainage, cisplatin and thiotepa (usually for lung and breast cancer, respectively) have reduced relapse, but with improved chemotherapy the systemic route is favoured, and planning should involve a multidisciplinary team of cardiologists and oncologists.[1] Radiation therapy is very effective for malignant effusion from radiosensitive tumours such as lymphomas and leukaemias.[1]
Tuberculous effusion
ESC 2025 says TB causes clinically significant effusion in approximately 90% of HIV-infected and 50%–70% of non-HIV-infected people living in developing countries with a high prevalence of TB.[1] In the effusive phase, pericardiocentesis usually yields bloody fluid, and effusive–constrictive physiology may emerge after drainage.[1] Pericardial drainage by any means, pericardiocentesis or window, is recommended as an essential part of the work-up of suspected TB pericarditis, for diagnosis and treatment.[1] ESC 2025: diagnostic pericardiocentesis is recommended in all patients with suspected tuberculous pericarditis when non-invasive tests have not confirmed the diagnosis, to identify the aetiological agent in pericardial fluid (Class I, Level C).[1] In a meta-analysis cited by ESC 2025, adenosine deaminase had a sensitivity of 90% and specificity of 86% for TB pericarditis.[1]
Purulent effusion
Purulent pericarditis is exceedingly rare in the Western world, under 1% of acute pericarditis (ESC 2025).[1] Suspicion of it is an indication for pericardial drainage regardless of the haemodynamic status.[1] Purulent effusions are often heavily loculated and likely to reaccumulate rapidly; subxiphoid pericardiotomy and rinsing of the pericardial cavity should be considered.[1]
Purulent pericarditis (ESC 2025, Recommendation Table 23)
| ESC 2025 recommendation (Recommendation Table 23) | Class | Level |
|---|---|---|
| Urgent pericardiocentesis and/or a surgical window in suspected purulent pericarditis, to establish a diagnosis | I | C |
| Intrapericardial fibrinolysis in purulent pericarditis, to allow complete drainage of purulent fluid and prevent constriction | IIa | B |
After cardiac surgery, procedures and myocardial infarction
- Iatrogenic cases: ESC 2025 says several post-traumatic cases are now iatrogenic, related to cardiovascular interventions.[1]
- Endomyocardial biopsy: its potential complications include cardiac perforation or tamponade (ESC 2025).[1]
- Early post-operative effusions: relatively common after cardiac surgery, and usually gone spontaneously in 7–10 days (ESC 2025).[1]
- Which ones matter: small asymptomatic effusions need no treatment; moderate to large effusions (one-third of cases) can progress to tamponade at a rate of 10% within 1 month after surgery and need pericardial decompression (ESC 2025).[1]
- No NSAID reflex: NSAIDs were ineffective for these asymptomatic effusions (diclofenac in the POPE trial) and may increase side effects; neither NSAIDs nor colchicine have to be given for post-operative effusions without systemic inflammation (ESC 2025).[1]
- After myocardial infarction: a post-infarction effusion over 10 mm at end-diastole should be investigated for possible subacute heart rupture (ESC 2025).[1]
Aortic dissection
ESC 2025 includes aortic rupture among the causes of surgical tamponade and acute aortic disease among the common causes of tamponade.[1] ESC 2024 (aortic diseases) lists cardiogenic shock secondary to pericardial tamponade among the major predictors of post-operative mortality in acute type A aortic dissection, while all such patients should receive surgery.[3] In its section on type A aortic dissection, ESC 2024 says to consider an emergency pericardial puncture for potential cardiac arrest from pericardial tamponade, as a temporary life-saving measure before transfer to the operating room (no class or level given).[3] ACC/AHA 2022 (aortic disease) calls untreated acute dissection of the ascending aorta highly lethal in symptomatic patients, with higher mortality when tamponade, with or without cardiogenic shock, is present or develops; suspected or diagnosed acute type A dissection warrants urgent surgical evaluation.[4]
Complications and pitfalls
- Draining too much: ESC 2025 says that, whenever possible, pericardiocentesis should not drain a large amount of fluid (usually under 500 mL), to prevent pericardial decompression syndrome.[1]
- Procedure complications: a variable risk of 4%–10%, depending on the type of monitoring, the operator's skill and the setting (emergent, urgent or elective); the most common include arrhythmias, coronary artery or cardiac chamber puncture, haemothorax, pneumothorax, pneumopericardium and hepatic injury (ESC 2025).[1]
- Ventilating the patient: positive airway pressure ventilation should be avoided in tamponade (ESC 2025).[1]
- Giving diuretics: diuretic therapy should be avoided in tamponade (ESC 2025).[1]
- Waiting for Beck triad: it may be lacking in medical tamponade with slowly accumulating fluid (ESC 2025).[1]
- Late CRP: CRP should be measured before pericardiocentesis because it can rise after the procedure (ESC 2025).[1]
- Missing the loculated effusion: after trauma or cardiac surgery an effusion may be loculated and compress locally (ESC 2025).[1]
- Missing the constrictive component: effusive–constrictive pericarditis occurs when constrictive physiology is uncovered after drainage of an effusion with tamponade; in patients who appear to have uncomplicated tamponade, the diagnosis usually becomes evident during pericardiocentesis (ESC 2025).[1]
Prognosis and follow-up
ESC 2025 ties prognosis to the cause.[1] The prognosis of an effusion is essentially related to its aetiology, moderate to large effusions are more common with specific aetiologies, and in general an effusion should be considered a marker of the severity of the underlying disease.[1] Tamponade with cancer and metastatic pericardial involvement has a bad short-term prognosis, as a sign of advanced disease, whereas tamponade with a final diagnosis of idiopathic pericarditis generally has a good long-term prognosis.[1]
- Small, idiopathic, asymptomatic effusion: overall good prognosis with a very low risk of complications, although not all studies concur; reassure, and no need to restrict physical activity if CRP is normal (ESC 2025).[1]
- Mild idiopathic effusion without symptoms: generally no specific monitoring (ESC 2025).[1]
- At least moderate effusion without symptoms: a reasonable follow-up is every 6 months, ideally in specialised centres; patients should be told to seek medical advice if symptoms appear, such as dyspnoea or fatigue and/or chest pain suggesting pericarditis (ESC 2025).[1]
- What to follow: mainly symptoms, with focused echocardiography for size and haemodynamics, plus CRP (ESC 2025).[1]
Special populations
Pregnancy
ESC 2025 says effusion is the most common pericardial manifestation in pregnancy.[1] It is typically benign, mild or moderate and well tolerated, resolves spontaneously after delivery, and needs no specific treatment in such cases.[1] However, an effusion may be associated with pre-eclampsia.[1]
Older patients
In two studies of acute pericarditis and one of recurrent pericarditis reviewed by ESC 2025, older patients less often had chest pain, fever, ST elevation and PR depression, and more often had dyspnoea, AF and pericardial effusion.[1]
Cancer, kidney failure and immunosuppression
Several groups score points in the Figure 12 triage: malignant disease (2), recent radiotherapy (1), chronic terminal renal failure (1) and immunosuppression (1).[1] ESC 2025 names renal failure among the most common causes of tamponade in clinical practice, and Table 8 lists uraemia among the less common causes.[1]
Evidence, guidelines and regional differences
The 2025 ESC myocarditis and pericarditis guideline is the formal ESC source for effusion and tamponade here; the 2015 ESC pericardial guideline appears only as dated history.[1][2]
ESC 2015 (history)
pericardial diseases guideline
- Tamponade without inflammatory signs: higher risk of a neoplastic aetiology (likelihood ratio 2.9); severe effusion without tamponade or inflammatory signs: usually chronic idiopathic (likelihood ratio 20)
- Moderate to large effusions (>10 mm) may worsen, and especially severe effusions may evolve towards tamponade in up to one-third of cases
- Working Group triage system: essentially based on expert consensus, and requiring additional validation in order to be recommended in clinical practice
ESC 2025
myocarditis and pericarditis guideline
- Effusion without raised inflammatory markers: increased risk of a neoplastic aetiology (likelihood ratio 2.9)
- Asymptomatic or oligosymptomatic, large, chronic, idiopathic effusion without evidence of pericarditis, managed conservatively: tamponade risk only 2.2% per year without reported deaths
- Triage criteria printed in Figure 12, based on expert consensus: immediate pericardiocentesis should be considered with more than 6 points from at least two categories
The 2.9 likelihood ratio has moved: ESC 2015 attached it to tamponade without inflammatory signs, ESC 2025 to an effusion without raised inflammatory markers.[2][1]
Aortic dissection guidelines
ESC 2024 (aortic diseases) says transthoracic echocardiography can identify complications of acute aortic syndromes such as tamponade, but its diagnostic accuracy for the aortic syndrome itself is limited.[3] ACC/AHA 2022 says CT can detect pericardial effusion and haemopericardium, and lists shock and tamponade among universally recognised risk factors for surgical mortality in acute type A dissection.[4]
ANZ practice
No NHFA/CSANZ guideline on pericardial effusion or tamponade was found in the census of PubMed and the guideline register for this topic, so the ESC 2025 rows are the guideline layer used here. Australian data come from New South Wales: a retrospective observational study of patients hospitalised with pericardial disease in all public and private hospitals in the state from 2004 to 2021.[5]
- Malignancy affected 19% of the cohort and, after adjustment, was associated with much higher in-hospital mortality, whether pericardial disease was the primary (OR 4.33) or secondary diagnosis (OR 2.67).[5]
- The investigators conclude that in-hospital mortality is low, about 1%, when pericardial disease is the primary diagnosis, but much worse when it is secondary, especially with comorbidities such as malignancy.[5]
- In a retrospective cohort of all hospitalised patients with pericardial disease in the NSW Admitted Patient Data Collection (2004–2021), 1.7% developed constrictive pericarditis, and constriction found during follow-up was more common after pericardiocentesis (HR 3.6).[6]
Guidelines checked
A row called the current one is so among the guidelines checked for this topic:
- Sources of the rows and statements used: ESC myocarditis and pericarditis (2025), with the 2015 ESC pericardial guideline as history only; ESC peripheral arterial and aortic diseases (2024); ACC/AHA aortic disease (2022).[1][2][3][4]
- No ACC/AHA guideline on pericardial disease was found in the census for this topic; the 2025 ACC concise clinical guidance on pericarditis is an expert consensus statement and is not held as text for this topic.
Exam pearls
- Effusion grading (ESC 2025, Table 10): mild under 10 mm, moderate 10–20 mm, large over 20 mm, measured as the maximal end-diastolic diameter.[1]
- Tamponade is a last-drop phenomenon: 200–300 mL can be enough when fluid collects quickly, while a slow effusion may reach 1 to 2 L (ESC 2025).[1]
- Pulsus paradoxus: inspiratory fall in systolic pressure of at least 10 mmHg, from exaggerated ventricular interdependence (ESC 2025).[1]
- ESC 2025 Table 17 lists diastolic collapse of the right atrium lasting more than 0.34 of the cardiac cycle length at a sensitivity above 90% and a specificity of 100%, and inferior vena cava plethora (dilatation over 20 mm with less than 50% respiratory reduction in diameter, as well as hepatic vein dilatation) at 97% sensitivity but only 40% specificity.[1]
- Figure 12 triage (criteria based on expert consensus): immediate pericardiocentesis should be considered with more than 6 points from at least two categories; orthopnoea and circumferential large effusion score 3 each (ESC 2025).[1]
- Avoid positive-pressure ventilation and diuretics; temporary fluid can bridge to urgent pericardiocentesis (ESC 2025).[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 (ESC 2025).[1]
References6ShowHide
- [1]Schulz-Menger J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J, 2025.PMID 40878297
- [2]Adler Y, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J, 2015.PMID 26320112
- [3]Mazzolai L, et al. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J, 2024.PMID 39210722
- [4]Isselbacher EM, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation, 2022.PMID 36322642
- [5]Kwan TN, et al. Prognosis of patients hospitalised with primary or secondary pericardial disease: an Australian population-based retrospective cohort study. BMJ Open, 2025.PMID 41407409
- [6]Kwan TN, et al. Epidemiology and Risk Factors for Constrictive Pericarditis in a Statewide Australian Cohort of Patients With Pericardial Disease. Can J Cardiol, 2026.PMID 40983194