pericardial effusion
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Etiology
- idiopathic
- infection (bacterial, viral, fungal, parasitic)
- trauma
- hemorrhage into the pericardial space
- metastatic lung cancer & breast cancer (most common cause)
- radiation therapy
- renal failure
- autoimmune disorders
Pathology
- response of the pericardium to inflammation
- accumulation of fluid between the pericardial layers
- exudation of fluid, fibrin & blood cells
- pericardial sac distends with slow accumulation of fluid
- rapid accumulation of only small amounts of fluid, especially with bleeding, may result in pericardial tamponade
- decreased ventricular volume & cardiac output
Clinical manifestations
- generally asymptomatic[4]
- dyspnea
- chest pain
- tachycardia
- jugular venous distension (JVD)
- pulsus paradoxus
- muffled heart sounds
- low systolic blood pressure
- low pulse pressure
Laboratory
- leukocytes in pericardial fluid
- 2000/uL (lymphocyte predominant) not indicative of autoimmune disease
- lymphocyte predominance suggests consideration of tuberculosis
Diagnostic procedures
- electrocardiogram: low voltage, electrical alternans[4]
- repeat echocardiogram* for idiopathic asymptomatic pericardial effusion[4]
- pericardiocentesis*
- fever, pleuritic chest pain, &/or ECG changes present
- idiopathic pericardial effusion not resolved within 3 months[4]
* despite that metastatic lung cancer is among the most common causes of pericardial effusion & the pericardial effusion was incidentally noted upon screening for lung cancer with low-dose CT, repeat echocardiogram is recommended vs pericardiocentesis
Radiology
- chest X-ray
- enlarged heart[4]
- 250 mL of pericardial effusion necessary before it can be seen on chest x-ray
- echocardiogram
- ultrasound guided pericardiocentesis if indicated
Complications
- cardiac tamponade (7-10%)[2]
Differential diagnosis
- restrictive cardiomyopathy
- right-sided heart failure, no muffled heart sounds [NEJM knowledge+]
- constrictive pericarditis
- echocardiogram or CT of thorax distinguishes
Management
- most cases can be managed with a combination of drugs
- an asymptomatic idiopathic pericardial effusion does not require immediate diagnostic or therapeutic intervention
- fever, pleuritic chest pain, &/or ECG changes present
- non-steroidal anti-inflammatory agents (NSAIDs)
- colchicine
- NSAIDs + colchicine 1st line for 1st episode
- after repeat echocardiogram for idiopathic pericardial effusion
- glucocorticoids
- diuretics
- an asymptomatic idiopathic pericardial effusion does not require immediate diagnostic or therapeutic intervention
- pericardiocentesis may be therapeutic as well as diagnostic
- pericardiotomy for large pericardial effusions & recurrent malignant pericardial effusions[6][7]
- pericardiectomy may be required if constriction of the heart is severe or persists
- requires general anesthesia & is associated with higher perioperative risk than pericardiotomy[6][7]
More general terms
More specific terms
Additional terms
References
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 51
- ↑ 2.0 2.1 Zeller JL et al, Pericardial effusion JAMA 2007, 297:1844
- ↑ Roy CL et al, Does this patient with a pericardial effusion have a cardiac tamponade? JAMA 2007, 297:1810
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Medical Knowledge Self Assessment Program (MKSAP) 16, 17. American College of Physicians, Philadelphia 2012, 2015
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ Apodaca-Cruz A, Villarreal-Garza C, Torres-Avila B et al Effectiveness and prognosis of initial pericardiocentesis in the primary management of malignant pericardial effusion. Interact Cardiovasc Thorac Surg. 2010 Aug;11(2):154-61 PMID: https://pubmed.ncbi.nlm.nih.gov/20504889
- ↑ 6.0 6.1 6.2 Burazor I, Imazio M, Markel G, Adler Y. Malignant pericardial effusion. Cardiology. 2013;124(4):224-32 PMID: https://pubmed.ncbi.nlm.nih.gov/23571453
- ↑ 7.0 7.1 7.2 Vaitkus PT, Herrmann HC, LeWinter MM. Treatment of malignant pericardial effusion JAMA. 1994 Jul 6;272(1):59-64. PMID: https://pubmed.ncbi.nlm.nih.gov/8007081 Review.
- ↑ Hoit BD. Pericardial effusion and cardiac tamponade pathophysiology and new approaches to treatment. Curr Cardiol Rep. 2023;25:1003-1014. PMID: https://pubmed.ncbi.nlm.nih.gov/37515704
- ↑ Lazaros G, Vlachopoulos C, Lazarou E, Tsioufis K. New Approaches to Management of Pericardial Effusions. Curr Cardiol Rep. 2021 Jul 1;23(8):106. PMID: https://pubmed.ncbi.nlm.nih.gov/34196832 Free PMC article. Review.