Pericardial Effusion - Workup and management

History

Cardiovascular symptoms in pericardial effusion can include the following:

Chest pain, pressure, discomfort - Characteristically, pericardial pain may be relieved by sitting up and leaning forward and is intensified by lying supine.

·        Light-headedness, syncope

·        Palpitations

Respiratory symptoms can include the following:

·        Cough

·        Dyspnea

·        Hoarseness

Neurologic symptoms of pericardial effusion can include anxiety and confusion, while hiccoughs may occur as a gastrointestinal (GI) symptom.

Signs and symptoms

Signs and symptoms of pericardial effusion include the following:

Chest pain, pressure, discomfort

Light-headedness, syncope

Palpitations

Cough

Dyspnea

Hoarseness

Anxiety and confusion

Hiccoughs

See Clinical Presentation for more detail.

Diagnosis

Examination findings in patients with pericardial effusion include the following:

Classic Beck triad of pericardial tamponade: Hypotension, muffled heart sounds, jugular venous distention

Pulsus paradoxus

Pericardial friction rub

Tachycardia

Hepatojugular reflux

Tachypnea

Decreased breath sounds

Ewart sign: Dullness to percussion beneath the angle of left scapula

Hepatosplenomegaly

Weakened peripheral pulses, edema, and cyanosis

Lab tests

The following laboratory studies may be performed in patients with suspected pericardial effusion:

Electrolyte levels

CBC count with differential

Cardiac biomarker levels (eg, troponin, CK-MB, LDH)

Tests for other markers of inflammation (eg, ESR, CRP)

TSH level

Blood cultures

RF levels

Immunoglobulin complex tests

ANA tests

Complement levels

Pericardial fluid analysis

Early in the course of acute pericarditis, the ECG typically displays diffuse ST elevation in association with PR depression; the ST elevation is usually present in all leads except for aVR, although in postmyocardial infarction pericarditis, the changes may be more localized.

Specific tests for infectious diseases or other conditions may also be warranted, based upon clinical suspicion, such as the following:

Viral cultures

Tuberculin skin testing or QuantiFERON-TB assay

Rickettsial antibodies

HIV serology

Adenosine deaminase levels

CEA levels

PCR

Imaging studies

Echocardiography is the imaging modality of choice for the diagnosis of pericardial effusion and includes the following techniques:

2-D echocardiography

M-mode echocardiography: Adjunct to 2-D echocardiography

Doppler echocardiography

Transesophageal echocardiography

Intracardiac echocardiography

Other radiologic studies used in the evaluation of pericardial effusion include the following:

Chest radiography

Chest CT Scanning and MRI: May be superior to echocardiography in detecting loculated pericardial effusions

Procedures

Procedures that may be used in patients with pericardial effusion include the following:

Diagnostic and/or therapeutic pericardiocentesis

Diagnostic pericardioscopy

Placement of a pulmonary artery catheter

See Workup for more detail.

Management

Most acute idiopathic or viral pericarditis occurrences are self-limited and respond to treatment with an NSAID. Prednisone may be administered for severe inflammatory pericardial effusions or when NSAID treatment has failed.

Autoimmune pericardial effusions may respond to treatment with anti-inflammatory medications. In general, selection of an agent depends on the severity of the patient's symptoms and the tolerability and adverse-effect profiles of the medications.

Pharmacotherapy for pericardial effusion includes use of the following agents, depending on the etiology:

NSAIDs (eg, indomethacin, ibuprofen, naproxen, diclofenac, ketoprofen, aspirin)

Corticosteroids (eg, prednisone, methylprednisolone, prednisolone)

Anti-inflammatory agents (eg, colchicine)

Antibiotics (eg, vancomycin, ceftriaxone, ciprofloxacin, isoniazid, rifampin, pyrazinamide, ethambutol)

Antineoplastic therapy (eg, systemic chemotherapy, radiation)

Sclerosing agents (eg, tetracycline, doxycycline, cisplatin, 5-fluorouracil)

Hemodynamic support for pericardial effusion includes the following:

Hemodynamic monitoring with a balloon flotation pulmonary artery catheter

IV fluid resuscitation

Surgical treatments for pericardial effusion include the following:

Pericardiostomy

Pericardotomy

Thoracotomy

Sternotomy

Pericardiocentesis

Pericardial Effusion- Management

Approach Considerations

Pharmacotherapy for pericardial effusion includes use of the following agents, depending on etiology:

Aspirin/NSAIDs

Colchicine

Steroids

Antibiotics

Antineoplastic therapy (eg, systemic chemotherapy, radiation) in conjunction with pericardiocentesis has been shown to be effective in reducing recurrences of malignant effusions. Corticosteroids and NSAIDs are helpful in patients with autoimmune conditions.

Pericardial sclerosis

Several pericardial sclerosing agents have been used with varying success rates (eg, tetracycline, doxycycline, cisplatin, 5-fluorouracil). The pericardial catheter may be left in place for repeat instillation if necessary until the effusion resolves.

Complications include intense pain, atrial dysrhythmias, fever, and infection. Success rates are reported to be as high as 91% at 30 days.

Surgery

Surgical treatments for pericardial effusion include the following:

Pericardiostomy

Pericardotomy

Thoracotomy

Sternotomy

Pericardiocentesis

Inpatient care

Patients with pericardial effusion who present with significant symptoms or cardiac tamponade require emergent treatment and admission to the intensive care unit (ICU). The pericardial catheter (if placed) should be removed within 24-48 hours to avoid infection. Symptomatic patients should remain hospitalized until definitive treatment is accomplished and/or symptoms have resolved

Outpatient care

Patients should be educated with regard to symptoms of increasing pericardial effusion and should be evaluated whenever these symptoms begin to occur. Indications for echocardiography after diagnosis include the following:

A follow-up imaging study to evaluate for recurrence/constriction - Repeat studies may be performed to answer specific clinical questions.

The presence of large or rapidly accumulating effusions - To detect early signs of tamponade

Transfer

Symptomatic patients requiring treatment (who are surgical candidates) should receive care at an institution with cardiothoracic surgery capabilities.

Consultations

A cardiologist should be involved in the care of patients with pericardial effusion. Cardiothoracic surgery may be required for recurrent or complicated cases.

Pericardial Effusion - Prognosis and Complications

Prognosis

Most patients with acute pericarditis recover without sequelae. Predictors of a worse outcome include the following:

Fever greater than 38°C

Symptoms developing over several weeks in association with immunosuppressed state

Traumatic pericarditis

Pericarditis in a patient receiving oral anticoagulants

A large pericardial effusion (>20 mm echo-free space or evidence of tamponade)

Failure to respond to nonsteroidal anti-inflammatory drugs (NSAIDs)

In a series of 300 patients with acute pericarditis, 254 (85%) did not have any of the high-risk characteristics and had no serious complications. Of these low-risk patients, 221 (87%) were managed as outpatients and the other 13% were hospitalized when they did not respond to aspirin.

Patients with symptomatic pericardial effusions from HIV/AIDS or cancer have high short-term mortality rates.

Morbidity and mortality

The morbidity and mortality of pericardial effusion is dependent on etiology and comorbid conditions. Idiopathic effusions are well tolerated in most patients. As many as 50% of patients with large, chronic effusions (effusions lasting longer than 6 months) have been found to be asymptomatic during long-term follow-up.

Pericardial effusion is the primary or contributory cause of death in 86% of cancer patients with symptomatic effusions. The survival rate for patients with HIV and symptomatic pericardial effusion is 36% at 6 months and 19% at 1 year.

Pericardial tamponade

Pericardial tamponade, which is heralded by the equalization of diastolic filling pressures, can lead to severe hemodynamic compromise and death. It is treated with expansion of intravascular volume (small amounts of crystalloids or colloids may lead to improvement, especially in hypovolemic patients) and urgent pericardial drainage. Positive-pressure ventilation should be avoided, if possible, as this decreases venous return and cardiac output. Vasopressor agents are of little clinical benefit.

Pericardial Effusion- Epidemiology

Few large studies have characterized the epidemiology of pericardial effusion; however, the available data consistently show that pericardial effusion is more prevalent than is clinically evident. A higher incidence of it is associated with certain diseases.

Small pericardial effusions are often asymptomatic, and pericardial effusion has been found in 3.4% of subjects in general autopsy studies.

A wide variety of malignant neoplasms and hematologic malignancies can lead to pericardial effusion. Data on the prevalence varies, with some studies showing the presence of pericardial effusion as high as 21% in such patients. A large study by Bussani et al showed cardiac metastases (9.1%) and pericardial metastases (6.3%) in cases of death from all causes in individuals with an underlying carcinoma at autopsy.[6] As previously mentioned, malignancies with the highest prevalence of pericardial effusion include lung (37% of malignant effusions) and breast (22%) malignancies, as well as leukemia/lymphoma (17%).

Patients with HIV, with or without acquired immunodeficiency syndrome (AIDS), are also found to have an increased prevalence of pericardial effusion.Studies have shown the prevalence of pericardial effusion in these patients to range from 5-43%, depending on the inclusion criteria, with 13% having moderate to severe effusion. The incidence of pericardial effusion in patients infected with HIV has been estimated at 11%; however, it appears that highly active antiretroviral therapy (HAART) may have reduced the incidence of HIV-associated effusions.

Race- and age-related demographics

No consistent difference among races is reported in the literature. AIDS patients with pericardial effusion are more likely to be white.

Pericardial effusion is observed in all age groups. The mean occurrence is in the fourth or fifth decades, although it is earlier than this in patients with HIV.

Pericardial Effusion - Etiology

Etiology

The cause of abnormal fluid production depends on the underlying etiology, but it is usually secondary to injury or insult to the pericardium (ie, pericarditis). Transudative fluids result from obstruction of fluid drainage, which occurs through lymphatic channels. Exudative fluids occur secondary to inflammatory, infectious, malignant, or autoimmune processes within the pericardium.

In up to 60% of cases, pericardial effusion is related to a known or suspected underlying process. Therefore, the diagnostic approach should give strong consideration to coexisting medical conditions.

Idiopathic

In many cases, the underlying cause is not identified. However, this often relates to the lack of extensive diagnostic evaluation.

Infectious

Human immunodeficiency virus (HIV) infection can lead to pericardial effusion through several mechanisms, including the following:

Secondary bacterial infection

Opportunistic infection

Malignancy (Kaposi sarcoma, lymphoma)

"Capillary leak" syndrome, which is associated with effusions in other body cavities

The most common cause of infectious pericarditis and myocarditis is viral. Common etiologic organisms include coxsackievirus A and B, and hepatitis viruses. Other forms of infectious pericarditis include the following:

Pyogenic - Pneumococci, streptococci, staphylococci, Neisseria, Legionella species

Tuberculous

Fungal - Histoplasmosis, coccidioidomycosis, Candida

Syphilitic

Protozoal

Parasitic

Neoplastic

Neoplastic disease can involve the pericardium through the following mechanisms:

Direct extension from mediastinal structures or the cardiac chamber

Retrograde extension from the lymphatic system

Hematologic seeding

Malignancies with the highest prevalence of pericardial effusion include lung (37% of malignant effusions) and breast (22%) malignancies, as well as leukemia/lymphoma (17%). However, patients with malignant melanoma or mesothelioma also have a high prevalence of associated pericardial effusions.

Postoperative/postprocedural

Pericardial effusions are common after cardiac surgery. In 122 consecutive patients studied serially before and after cardiac surgery, effusions were present in 103 patients; most appeared by postoperative day 2, reached their maximum size by postoperative day 10, and usually resolved without sequelae within the first postoperative month.

In a retrospective survey of more than 4,500 postoperative patients, only 48 were found to have moderate or large effusions by echocardiography; of those, 36 met diagnostic criteria for tamponade. The use of preoperative anticoagulants, valve surgery, and female sex were associated with a higher prevalence of tamponade.

Early chest tube removal following cardiac surgery, around midnight on the day of surgery, may be associated with an increased risk of postoperative pleural and/or pericardial effusions requiring invasive treatment.{ref 88} This may occur even if chest tube output during the last 4 hours is below 150 mL compared with removal of the tubes next morning.

Symptoms and physical findings of significant postoperative pericardial effusions are frequently nonspecific, and echocardiographic detection and echo-guided pericardiocentesis, when necessary, are safe and effective; prolonged catheter drainage reduces the recurrence rate.

Pericardial effusions in cardiac transplant patients are associated with an increased prevalence of acute rejection.

Other

Less common causes of pericardial effusion include the following:

Uremia

Myxedema

Severe pulmonary hypertension

Radiation therapy

Acute myocardial infarction - Including the complication of free wall rupture

Aortic dissection - Leading to hemorrhagic effusion from leakage into the pericardial sac

Trauma

Hyperlipidemia

Chylopericardium

Familial Mediterranean fever

Whipple disease

Hypersensitivity or autoimmune related - Systemic lupus erythematosus, [5] rheumatoid arthritis, ankylosing spondylitis, rheumatic fever, scleroderma, Wegener granulomatosis

Drug associated - Eg, procainamide, hydralazine, isoniazid, minoxidil, phenytoin, anticoagulants, methysergide

Pericardial Effusion

Pathophysiology

Clinical manifestations of pericardial effusion are highly dependent on the rate of accumulation of fluid in the pericardial sac. Rapid accumulation of pericardial fluid may cause elevated intrapericardial pressures with as little as 80 mL of fluid, while slowly progressing effusions can grow to 2 L without symptoms.

Understanding the properties of the pericardium can help to predict changes within the heart under physiologic stress.

By distributing forces across the heart, the pericardium plays a significant role in the physiologic concept of ventricular interdependence, whereby changes in pressure, volume, and function in one ventricle influence the function of the other.

The pericardium plays a pivotal role in cardiac changes during inspiration. Normally, as the right atrium and ventricle fill during inspiration, the pericardium limits the ability of the left-sided chambers to dilate. This contributes to the bowing of the atrial and ventricular septums to the left, which reduces left ventricular (LV) filling volumes and leads to a drop in cardiac output. As intrapericardial pressures rise, as occurs in the development of a pericardial effusion, this effect becomes pronounced, which can lead to a clinically significant fall in stroke volume and eventually progress to the development of pericardial tamponade.

The pericardium plays a beneficial role during hypervolemic states by limiting acute cardiac cavitary dilatation.

Pericardial Effusion

Definition.

Pericardial effusion is the presence of an abnormal amount of and/or an abnormal character to fluid in the pericardial space. It can be caused by a variety of local and systemic disorders, or it may be idiopathic.

Pericardial effusions can be acute or chronic, and the time course of development has a great impact on the patient's symptoms. Treatment varies, and is directed at removal of the pericardial fluid and alleviation of the underlying cause, which usually is determined by a combination of fluid analysis and correlation with comorbid illnesses.