Practice Essentials
Pericardial effusion is the presence of an abnormal amount of fluid 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. See the image below.
This echocardiogram shows a large amount of pericardial effusion (identified by the white arrows).
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 may be 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. Colchicine or prednisone may be administered for severe inflammatory pericardial effusions or when NSAID treatment has failed. Colchicine is preferred over steroids (unless specifically indicated), as the latter is associated with an increassed incidence of recurrent pericarditis.
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
See Treatment and Medication for more detail.