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