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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 without tamponade should be based on etiology

  • When the effusion is associated with acute pericarditis, treatment ...

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