If the effusion is small, there may be no symptoms as all, but as it accumulates the patients begin to have symptoms of dyspnea, that worsens over time, with an associated tachycardia. There may be symptoms of chest pain that is relieved on leaning forward. Some patients may report lightheadedness with syncope or near syncope. Symptomatic patients usually have evidence of right side heart compromise that may be assessed on echocardiography.

On examining the patient, there may be the classic triad of hypotension, decreased heart sounds and signs of increased jugular venous distension. There may be a pericardial friction rub and a positive hepatojugular rub. Pulsus paradoxus may occur which is defined as a drop of the systolic blood pressure of more than 10mmHg on inspiration due to falling cardiac output. Ewarts sign (Dullness to percussion under the angle of the left scapula) may be positive [6].

• Myxedema

  Abstract INTRODUCTION "Myxedema heart" was first described as a clinical entity by Zondek 1 in 1918. [annals.org]

  Echocardiographic evaluation of pericardial effusion in myxedema. Incidence and biochemical and clinical correlations. Circulation 1975; 52: 823-7. [ Links ] 3. Parving HH, Hansen JM, Nielson SL, Rossing N, Munck O, Lassen NA. [scielo.br]

  […] tuberculous, or idiopathic in origin) Autoimmune disease Postmyocardial infarction or cardiac surgery; sharp or blunt chest trauma, including a cardiac diagnostic or interventional procedure Malignancy, mostly metastatic; chemo, radiation to the chest Uremia; Myxedema [slideshare.net]

  Idiopathic Infection Autoimmune (SLE, rheumatoid arthritis, scleroderma) Dressler's and postpericardiotomy syndromes Neoplasm (lymphoma, lung or breast metastasis) Drug-induced (procainamide, hydralazine, phenytoin) Uremia Myxedema Congestive heart failure [stritch.luc.edu]

• Pleural Effusion

  KEYWORDS: Acute pancreatitis; pericardial effusion; pleural effusion [ncbi.nlm.nih.gov]

• Dyspnea

  An 84-year-old Japanese non-smoking woman with a history of lung cancer, treated by surgery, was admitted due to gradual worsening of dyspnea that had occurred over the previous month. [ncbi.nlm.nih.gov]

• Cough

  I have a patient with stage 4 lung cancer that presented with fatigue, cough, and loss of appetite. Initially they thought he had PNA but when they did an ECHO on day one they found a pericardial effusion (malignant). [forums.acdis.org]

  Symptoms of Pericardial Effusion There are many symptoms of this condition including: Shortness of breath or difficulty breathing Discomfort when breathing while lying down Chest pain Cough Low-grade fever Rapid heart rate Treatment of Pericardial Effusion [houstonmethodist.org]

  Symptoms may arise gradually or rapidly, depending on fluid accumulation rate, and may range from dyspnoea, chest pain, cough, palpitations and orthopnoea, to fatigue, anxiety and confusion. [oncologypro.esmo.org]

  […] disorders that can cause pericardial effusion include: Cancer Lupus Rheumatoid arthritis HIV/AIDS Hypothyroidism Uremia Symptoms of pericardial effusion Symptoms can mimic those of heart failure, including difficulty catching your breath, chest pain and coughing [wexnermedical.osu.edu]

• Orthopnea

  If pericardial effusion symptoms do occur, they might include: Shortness of breath or difficulty breathing (dyspnea) Discomfort when breathing while lying down (orthopnea) Chest pain, usually behind the breastbone or on the left side of the chest Chest [mayoclinic.com]

  The pressure from the outside causes the blood to pool back and accumulate in the lungs which causes the symptoms of orthopnea and dyspnea. [pericarditispain.info]

  […] interventricular septum shifts towards the left ventricle chamber ventricular diastolic filling stroke volume ( venous congestion) cardiac output References:[2] Clinical features Usually initially asymptomatic Shortness of breath, especially while lying down (orthopnea [amboss.com]

• Bronchial Breath Sounds

  Larger effusions cause muffled heart sounds and, rarely, Ewart's sign (dullness to percussion, bronchial breath sounds, and egophony below the angle of the left scapula). [clevelandclinicmeded.com]

• Dysphagia

  Dysphagia- due to compression of esophagus Nausea and abdominal discomfort- due to pressure of sub-diaphragmatic structure Hiccups- due to compression of the phrenic nerves Physical examination - 1. [iame.com]

  He had no history of congestive heart failure or dysphagia. [wjso.biomedcentral.com]

  Most patients are weak and faint at presentation and can have vague symptoms such as anorexia, dysphagia, and cough. The initial symptom may also be one of the complications of tamponade, such as renal failure. [rjmatthewsmd.com]

  Common associated signs and symptoms include low-grade intermittent fever, dyspnea/tachypnea (a frequent complaint and may be severe, with myocarditis, pericarditis, and cardiac tamponade), cough, and dysphagia. [pdfslide.us]

  Symptoms Signs Undifferentiated o Chest pain Ø Positional; relief when sitting forward with pericarditis o Back pain o Flank pain o Abdominal pain ·Undifferentiated o Dyspnea 13% with effusion5 o Orthopnea o PND Nonspecific/Constitutional o Nauseated o Dysphagia [saem.org]

• Hepatomegaly

  Radiologic examinations were carried out, and the computed tomography scan revealed a hepatomegaly and a chest X-ray showed evidence of a unilateral pleural effusion. [ncbi.nlm.nih.gov]

  For example, systolic blood pressure was higher than 100 mm Hg in 94% of patients, elevation of the jugular venous pressure was found in only 74%, hepatomegaly was present in 28%, and pulsus paradoxus was found in only 36% of patients. [heart.bmj.com]

  Symptoms and signs of peripheral venous congestion (eg, peripheral edema, neck vein distention, hepatomegaly) may appear with an early diastolic sound (pericardial knock), often best heard during inspiration. [merckmanuals.com]

• Chest Pain

  Sharp foreign body ingestion is extremely rare but poses devastating complications, and should be considered in the differential diagnosis of patients with otherwise unexplained chest pain. [ncbi.nlm.nih.gov]

  […] fullness When to see a doctor Call 911 or your local emergency number if you feel chest pain that lasts more than a few minutes, if your breathing is difficult or painful, or if you have an unexplained fainting spell. [mayoclinic.com]

• Heart Failure

  Presenting symptoms include heart failure, arrhythmias, sudden death, cyanosis and chest pain. But it can also present as recurrent pericardial effusion misdiagnosed as tuberculosis and other infectious causes. [ncbi.nlm.nih.gov]

  Symptoms also may occur due to diastolic heart failure (heart failure that occurs because the heart is unable to relax normally between each contraction due to the added compression).Symptoms of pericardial effusion include: Chest pressure or pain Shortness [my.clevelandclinic.org]

• Tachycardia

  Emergency physicians must maintain vigilance in suspecting pericardial effusion and tamponade in patients with known or suspected malignancy who present with tachycardia, dyspnea, and hypotension. [ncbi.nlm.nih.gov]

  Conclusions Among patients with cardiac tamponade, a minority will not have dyspnea, tachycardia, elevated jugular venous pressure, or cardiomegaly on chest radiograph. [jamanetwork.com]

  Clinical Presentation Significant symptoms only present with effusion leading to tamponade fatigue, dyspnea, chest discomfort, elevated jugular venous pressure, edema ECG findings — most commonly – sinus tachycardia, low QRS voltage, and electrical alternans [slideshare.net]

• Hypotension

  Emergency physicians must maintain vigilance in suspecting pericardial effusion and tamponade in patients with known or suspected malignancy who present with tachycardia, dyspnea, and hypotension. [ncbi.nlm.nih.gov]

  Pericardial effusion is initially asymptomatic, but cardiac tamponade has a distinct clinical presentation, including hypotension, tachycardia, jugular venous congestion, and pulsus paradoxus. [amboss.com]

  Recall Beck's triad of distended neck veins, distant heart sounds, and HYPOtension. This pt was teetering on HYPOtension and the decision was made to tap the effusion with cardiology in the ED. [em.emory.edu]

  […] pressure and mild hypotension 7. [slideshare.net]

• Pulsus Paradoxus

  Based on 1 study, the presence of pulsus paradoxus greater than 10 mm Hg in a patient with a pericardial effusion increases the likelihood of tamponade (likelihood ratio, 3.3; 95% CI, 1.8-6.3), while a pulsus paradoxus of 10 mm Hg or less greatly lowers [jamanetwork.com]

  patients with clinical signs of tachycardia ( 90 bpm), hypotension (systolic blood pressure 100 mmHg), elevated jugular venous pressure and/or pulsus paradoxus 10 mmHg plus evidence of a large pericardial effusion with echocardiographic signs of tamponade [clinicaltrials.gov]

  Pericardial effusion is initially asymptomatic, but cardiac tamponade has a distinct clinical presentation, including hypotension, tachycardia, jugular venous congestion, and pulsus paradoxus. [amboss.com]

  The absence of pulsus paradoxus (Table 1) makes this form difficult to recognize. [rjmatthewsmd.com]

  Pulsus paradoxus reflects a decrease in systolic BP with inspiration of more than 12 mm Hg. Pulsus paradoxus also occurs in severe asthma or COPD exacerbations. Treatment Many pericardial effusions do not require any therapy. [healio.com]

Initial workup will include an electrocardiogram which may show:

• Low voltage 
• Electric alterans 

A chest X-ray may show an enlarged globular heart. Echocardiogram is the most sensitive test for pericardial effusion and will also provide information about the estimated amount, the function of the ventricle and if they have been compromised by the effusion. The effusions are graded as mild (50-100mls), moderate (100-500mls) and severe (>500mls).

Establishing the cause is important in symptomatic effusions. This will entail ruling out the causes as listed in the etiology section and will require echocardiogram assisted pericardial effusion aspiration. The fluid is sent for the relevant tests for the underlying cause to be identified. MRI and CT Scan may be used to access the presence of effusion [7].

• Cardiomegaly on Chest X-ray

  We suggest that any patient who develops chest pain, tachycardia, cardiomegaly on chest X-ray or has signs of hypoxemia should be evaluated for PEF through echocardiography and tested for laboratory signs of TA-TMA. 10 Patients diagnosed with a moderate-to-large [nature.com]

  ECG may show low voltage complexes and electrical alternans, and cardiomegaly on chest X-ray [2,12,16]. [escardio.org]

• Chest X-Ray Abnormal

  X-ray Abnormal pericardial appearance on echocardiogram Test results can help distinguish between types of pericardial fluid and help diagnose the cause of fluid accumulation. [labtestsonline.org]

• X-Ray Abnormal

  […] ordered when someone has some combination of the following signs and symptoms : Chest pain, sharp or sometimes dull, that may be relieved by bending forward Coughing Difficulty breathing Fever Fatigue Changes in heart rhythm Enlarged heart size on chest X-ray [labtestsonline.org]

• Echocardiogram Abnormal

  abnormal Last Update: 2012-04-11 Usage Frequency: 2 Quality: Reference: Wikipedia Estonian Kardiomüopaatia, perikardi efusioon, perikardiit English Cardiomyopathy, pericardial effusion, pericarditis Last Update: 2012-04-11 Usage Frequency: 2 Quality: [mymemory.translated.net]

• Plasmodium Falciparum

  A blood malaria antigen test was positive for Plasmodium falciparum. One week after initiation of antimalarial medication, echocardiography revealed almost complete resolution of the pericardial effusion. [ncbi.nlm.nih.gov]

• Electrical Alternans

  Electrical alternans vs. pseudoelectrical alternans. [lifeinthefastlane.com]

  Diagnostics: Electrocardiogram See Cardiac Tamponade Low amplitude wave forms Electrical alternans VII. [fpnotebook.com]

• Pleural Effusion

  KEYWORDS: Acute pancreatitis; pericardial effusion; pleural effusion [ncbi.nlm.nih.gov]

Symptomatic effusion requires aspiration of the fluid, pericardiocentesis, and this may be done with ultrasound or echocardiogram guidance with drainage insertion. Pericardiocentesis has to be done rapidly in patients with compromised hemodynamics. Treatment of underlying causes such as tuberculosis is required to prevent reaccumulation [8] [9] [10].

The outcome is highly dependent on the cause. Most patients with acute pericarditis present with minimal effusions and many will have a self-limiting course. Viral causes as well are usually self-limiting and will heal with no long term complication. Other causes such a malignancy have poor outcomes. The mortality of HIV patients that have symptomatic effusions is low. If the patient is in cardiac tamponade, this has to be relieved or it could be fatal.

There are many causes of a possible pericardial effusion.

• Acute pericarditis 
• Viral causes such as varicella zoster virus (VZV), coxsackievirus A or B, influenza virus, herpes simplex virus, adenovirus, cytomegalovirus, Epstein-Barr virus, or human immunodeficiency virus (HIV)
• Mycobacterium 
• Whipple disease 
• Pyogenic causes such as streptococcus and staphylococcus
• Post myocardial infarction
• Malignancies such as lymphoma or direct spread of nearby tumor
• Uremia
• Traumatic 
• Autoimmune diseases, such as rheumatoid arthritis, sarcoidosis and systemic lupus erythematosus
• Myxedema
• Drugs like hydralazine, isoniazid, minoxidil, phenytoin, anticoagulants [1] [2]

Small pericardial effusions are usually not asymptomatic and have been found in some autopsy studies to have a prevalence of 3%. There are some subsets of patients who have an increased risk of pericardial effusion. These include those with lung cancer. Up to 21% of these patients may have an effusion. Patients with the human immunodeficiency virus have a higher incidence of effusions as well and it has been noted in up to 13% [3] [4].

The clinical manifestations of pericardial effusion are dependent on the rate of fluid accumulation. A rapid increase of a small amount of fluid may cause significant symptoms, but the pericardium may accomodate up to 2l slowly over time. The various causes listed above cause the pericardium to secrete more fluid by various methods, either by increased production or decreased absorption [5].

Prevention is difficult as there are numerous causes of effusion. Preventable causes include vaccinating against viruses that may cause the effusion. Otherwise appropriate management of underlying causes should be done (e.g appropriate dialysis for end stage renal disease patients)

The pericardium has several functions:

• Restraining force, that prevents sudden dilation of the cardiac chambers.
• Maintaining the anatomic position of the heart.
• Reduces friction between the heart and it surrounding structures. The small pericardial fluid which is an ultrafiltrate that acts a lubricant 
• Stops the spread of infections from the lungs and pleural cavities to the heart [1]

Pericardial effusions, abnormal accumulations of fluid in the pericardial space, may develop slowly or quickly. The normal pericardium can stretch slowly over time to accommodate a gradual increase in the fluid, but it has its limits and the accumulating fluid will exert its pressure on the heart and compromise its function (cardiac tamponade).

It may be sub-classified into:

• Acute effusion: < 6 weeks
• Subacute effusion: 6 weeks to >6months 
• Chronic effusion: > 6months 

• Definition: Pericardial effusion is the accumulation of fluid in the sac that encloses the heart. In most cases it is associated with inflammation, which could be caused by viruses most commonly. 
• Cause: There are many causes, which differ from country to country with some countries reporting cancers as the highest cause of symptomatic pericardial effusions. 
• Symptoms. This may include easy fatigability, difficulty in breathing, and sometimes fainting. There may be a cough, lightheadedness and awareness of a heart beat at fast heart rate. If the pericardial effusion is large enough, it can cause the heart to function poorly and fail, which may cause death if not treated well.
• Diagnosis: This is diagnosed with different methods but echocardiography (ultrasound of the heart) is the most widely used method. Other tests such as CT scans may be used. Some fluid may be taken for analysis, to try and find out the cause. 
• Treatment: If the symptoms are bad enough the doctor may remove the fluid to offer you some relief. Then they will try to find out the cause and treat it as required.

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2. Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet 2004; 363:717.
3. Lind A, Reinsch N, Neuhaus K, et al. Pericardial effusion of HIV-infected patients ? Results of a prospective multicenter cohort study in the era of antiretroviral therapy. Eur J Med Res. Nov 10 2011;16(11):480-3.
4. Meenakshisundaram R, Sweni S, Thirumalaikolundusubramanian P. Cardiac isoform of alpha 2 macroglobulin: a marker of cardiac involvement in pediatric HIV and AIDS. Pediatr Cardiol. Nov 14 2009;
5. Zayas R, Anguita M, Torres F, et al. Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol 1995; 75:378.
6. Sagristà-Sauleda J, Mercé J, Permanyer-Miralda G, Soler-Soler J. Clinical clues to the causes of large pericardial effusions. Am J Med 2000; 109:95.
7. Klein AL, Abbara S, Agler DA, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2013; 26:965.
8. Imazio M, Adler Y. Management of pericardial effusion. Eur Heart J 2013; 34:1186.
9. Kopecky SL, Callahan JA, Tajik AJ, Seward JB. Percutaneous pericardial catheter drainage: report of 42 consecutive cases. Am J Cardiol 1986; 58:633.
10. Tsang TS, Enriquez-Sarano M, Freeman WK, et al. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and