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pericardial effusion

Etiology: 1) idiopathic 2) infection (bacterial, viral, fungal, parasitic) 3) trauma 4) hemorrhage into the pericardial space - trauma, myocardial infarction, aortic rupture - cardiac surgery: CABG 5) metastatic lung cancer & breast cancer (most common cause) 6) radiation therapy 7) renal failure 8) autoimmune disorders - hypothyroidism - inflammatory bowel disease - rheumatoid arthritis Pathology: 1) response of the pericardium to inflammation - accumulation of fluid between the pericardial layers 2) exudation of fluid, fibrin & blood cells 3) pericardial sac distends with slow accumulation of fluid 4) rapid accumulation of only small amounts of fluid, especially with bleeding, may result in pericardial tamponade 5) decreased ventricular volume & cardiac output Clinical manifestations: 1) generally asymptomatic [4] 2) dyspnea 3) chest pain 4) tachycardia 5) jugular venous distension (JVD) 6) pulsus paradoxus 7) muffled heart sounds 8) low systolic blood pressure 9) low pulse pressure Laboratory: - leukocytes in pericardial fluid - 2000/uL (lymphocyte predominant) not indicative of autoimmune disease - lymphocyte predominance suggests consideration of tuberculosis Special laboratory: - electrocardiogram: low voltage, electrical alternans [4] - pericardiocentesis - idiopathic pericardial effusion not resolved within 3 months [4] Radiology: 1) chest X-ray - enlarged heart [4] - 250 mL of pericardial effusion necessary before it can be seen on chest x-ray 2) 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: 1) most cases can be managed with a combination of drugs - non-steroidal anti-inflammatory agents (NSAIDs) - colchicine - NSAIDs + colchicine 1st line for 1st episode - glucocorticoids - diuretics 2) pericardiocentesis may be therapeutic as well as diagnostic 3) pericardiotomy for large pericardial effusions & recurrent malignant pericardial effusions [6,7] 4) 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]

Related

cardiac tamponade; pericardial tamponade pericarditis pericardium

Specific

effusive constrictive pericarditis

General

pericardial disease

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 51
  2. Zeller JL et al, Pericardial effusion JAMA 2007, 297:1844
  3. Roy CL et al, Does this patient with a pericardial effusion have a cardiac tamponade? JAMA 2007, 297:1810
  4. Medical Knowledge Self Assessment Program (MKSAP) 16, 17. American College of Physicians, Philadelphia 2012, 2015
  5. 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: 20504889
  6. Burazor I, Imazio M, Markel G, Adler Y. Malignant pericardial effusion. Cardiology. 2013;124(4):224-32 PMID: 23571453
  7. Vaitkus PT, Herrmann HC, LeWinter MM. Treatment of malignant pericardial effusion JAMA. 1994 Jul 6;272(1):59-64. PMID: 8007081 Review.