Pericardial Effusion

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• Echocardiographic demonstration of pericardial fluid

GENERAL CONSIDERATIONS

• Normal pericardial space contains 15–25 mL of plasma ultrafiltrate

• Symptoms are related to the rate of fluid accumulation

• Causes of pericardial effusion:

  • – Malignancy

  • – Idiopathic

  • – Congestive heart failure

  • – Valvular heart disease

  • – Infection (bacterial, viral, fungal, parasitic, tuberculosis, HIV)

  • – Autoimmune or connective tissue diseases

  • – Trauma

  • – Uremia

  • – Drugs

  • – Postpericardiotomy syndrome

  • – Heart transplantation

  • – Chylopericardium

  • – Myxedema

  • – Radiation

• Most common malignant effusions are lung, breast, and leukemia/lymphoma

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Small pericardial effusions are usually asymptomatic

• Patients with pericarditis may complain of chest pain, pressure, discomfort, palpitations

• Patients with large pericardial effusions may experience a cough, hiccups, dyspnea, or hoarseness

• Patients with cardiac tamponade may present with lightheadedness, syncope, anxiety, and confusion

PHYSICAL EXAM FINDINGS

• Muffled heart sounds in patients with large effusions

• Pericardial friction rub in patients with pericarditis

• Tachycardia

• Signs of cardiac tamponade:

  • – Beck’s triad (hypotension, muffled heart sounds, jugular venous distention)

  • – Pulsus paradoxus (exaggerated fall in systemic blood pressure > 10 mm Hg with inspiration)

• Decreased pulse pressure

• Ewart’s sign (dullness to percussion beneath the angle of the left scapula from compression of the left lung by pericardial fluid)

• Hepatosplenomegaly

• Edema

• Cyanosis

DIFFERENTIAL DIAGNOSIS

• Pericardial fat is indistinguishable on echocardiogram

• Chylous pericardial fluid may be present from thoracic duct obstruction

DIAGNOSTIC EVALUATION

LABORATORY TESTS

• CBC with differential

• Troponin and B-type natriuretic peptide

• Thyroid-stimulating hormone

• Rheumatoid factor, antinuclear antibodies, immunoglobulin complexes, and complement levels in some cases of suspected rheumatologic illness

ELECTROCARDIOGRAPHY

• Low voltage

• Sinus tachycardia

• Electrical alternans

• PR-segment depression and diffuse ST-segment elevation in the presence of pericarditis

IMAGING STUDIES

• Chest x-ray: enlarged cardiac silhouette (“water bottle heart”)

• Echocardiography:

  • – The effusion appears as an “echo-free” space between the visceral and parietal pericardium

• CT scan of the chest and cardiac MRI are highly sensitive for diagnosing pericardial effusion and determining the presence of pericardial thickening and masses

DIAGNOSTIC PROCEDURES

• Transesophageal echocardiography: useful in characterizing loculated effusions

TREATMENT

CARDIOLOGY REFERRAL

• A newly diagnosed patient should probably be seen at least once by a cardiologist

• Symptomatic patient with a known pericardial effusion

• Enlarging pericardial effusion by serial echocardiography

HOSPITALIZATION CRITERIA

• Large pericardial effusion

• Suspected cardiac tamponade

• Patients who undergo elective percutaneous or surgical pericardial drainage

MEDICATIONS

• Treatment of pericardial effusion ...