cardio.cardiac-tamponade.malignant.v1

Cardiac tamponade — malignant pericardial effusion

cardiologyacuteadultacuteinpatienttransitionoutpatient

Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to malignant pericardial effusion (lung ~30%, breast ~25%, lymphoma, leukemia, melanoma, GI cancers). Inherits drainage + bridge regimen from parent via routing; specializes for malignant-specific durability strategy: surgical pericardial window (subxiphoid or VATS) preferred over balloon pericardiotomy given >50% 90-day recurrence post-pericardiocentesis-alone (El Haddad JACC 2015 PMID 26515995); intrapericardial cytotoxic instillation (cisplatin lung, bleomycin, mitomycin) for refractory recurrence per Maisch ESC 2013 + Patel Eur J Cancer 2013 PMID 23290429; multidisciplinary oncology + cardiology + thoracic surgery + palliative care coordination per NCCN palliative 2024. Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (malignant-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated cytotoxic drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute.

Entry points (4)

problem_list
Known active malignancy (lung, breast, lymphoma, leukemia, melanoma, GI) presenting with new dyspnea + hypotension + JVD (Lestuzzi Heart 2010; Ristić EHJ 2014)
known_active_malignancy_with_dyspnea
imaging
Echo: pericardial effusion (often large >2 cm) + RV diastolic collapse / IVC plethora in cancer patient (ESC 2015 §Neoplastic Pericardial Disease)
echo_large_effusion_in_oncology_pt
imaging
Incidental pericardial effusion on staging CT in oncology patient — outpatient triage to echo + tamponade screen (Imazio JACC 2020 PMID 32919577)
incidental_effusion_on_staging_ct
symptom
Recurrent effusion within 30-90 days of prior pericardiocentesis in cancer patient → pericardial window indication (El Haddad JACC 2015 PMID 26515995)
recurrent_effusion_post_pericardiocentesis

Required inputs (9)

agerequired
demographic • used at CONTEXT
Age modifies cancer-type distribution and surgical candidacy (Khandaker Mayo Clin Proc 2010 PMID 20656240)
sbprequired
vital • used at RED_FLAGS
Hypotension is part of Beck triad; pulsus paradoxus measurement (Spodick Circulation 2003)
hrrequired
vital • used at CONTEXT
Compensatory tachycardia in tamponade physiology (ESC 2015)
echorequired
imaging • used at INITIAL_WORKUP
Definitive bedside dx — chamber collapse, IVC, swinging heart (ESC 2015 Class I)
cancer_type_and_stagerequired
history • used at CONTEXT
Lung/breast = 55% of malignant pericardial effusions; histology drives intrapericardial cytotoxic choice (Lestuzzi Heart 2010; Maisch ESC 2013)
systemic_anticancer_therapy_statusrequired
history • used at CONTEXT
On active chemo / immunotherapy / radiation? — affects bleeding risk + drug interactions (NCCN palliative 2024)
prior_pericardiocentesis
history • used at CONTEXT
Recurrence post-drainage drives pericardial window decision (El Haddad PMID 26515995)
plateletsrequired
lab • used at INITIAL_WORKUP
Thrombocytopenia from chemo/marrow infiltration drives bleeding risk during drainage (NCCN 2024)
inrrequired
lab • used at INITIAL_WORKUP
Coagulopathy in advanced cancer / liver mets (NCCN 2024)

12-phase flow (9)

1FRAME
Malignant tamponade — drainage is bridge; surgical window typically required for durability given >50% 90-day recurrence post-pericardiocentesis-alone (El Haddad PMID 26515995; ESC 2015 §Neoplastic)
inputs: sbp
advance: cancer-context tamponade physiology suspected
2ENTRY
Recognize Beck triad in oncology patient; rule in malignant etiology vs radiation pericarditis vs chemo-cardiotoxicity vs incidental viral (Lestuzzi Heart 2010)
inputs: age
advance: oncology context confirmed
3CONTEXT
Document cancer type, stage, performance status, current systemic therapy, prior pericardial procedures, goals of care (NCCN palliative 2024)
inputs: cancer_type_and_stage, systemic_anticancer_therapy_status, prior_pericardiocentesis
advance: cancer context + GoC captured
4RED_FLAGS
Obstructive shock physiology (ESC 2015); separately screen for SVC syndrome and tumor embolism (Imazio JACC 2020 PMID 32919577)
inputs: sbp, hr
advance: shock recognized → drainage prepared with oncology + thoracic surgery on standby
5INITIAL_WORKUP
STAT echo, ECG, CXR, troponin, BMP, CBC, coags, type & screen (drainage with thrombocytopenia or coagulopathy needs blood-bank backup; NCCN 2024)
inputs: echo, platelets, inr
actions: panel.cardiac, panel.coag, panel.cbc
advance: echo confirms tamponade physiology + bleeding risk quantified
6DIFFERENTIAL
Confirm malignant etiology via fluid: cytology + flow cytometry + cell block (sensitivity 70-90% pooled; Lestuzzi Heart 2010); consider immunohistochemistry for primary site identification if cancer of unknown primary
advance: fluid sent for full malignant work-up
7TREATMENT
Step 1 echo-guided pericardiocentesis with extended pigtail drainage (24-72h); Step 2 surgical pericardial window (subxiphoid or VATS) — preferred over balloon pericardiotomy for durability; Step 3 intrapericardial cytotoxics (cisplatin lung ca, bleomycin, mitomycin) for refractory recurrence per Maisch ESC 2013 + Patel Eur J Cancer 2013 PMID 23290429
inputs: sbp
advance: pericardial fluid drained + window vs catheter strategy determined
8DISPOSITION
CCU/ICU post-drain; thoracic surgery handover for window; oncology consult for primary anti-cancer therapy intensification — multidisciplinary tumor board review within 1 week (NCCN palliative 2024)
advance: multidisciplinary disposition confirmed
9MONITORING
Re-accumulation surveillance (echo q12-24h initially then weekly outpatient); fluid analysis (cytology, flow cytometry, cell block, cell count, glucose, LDH, ADA); CRP trend; oncologic disease-status updates (Imazio JACC 2020)
actions: panel.pleural
advance: fluid analysis returned + tumor board disposition