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Pericardial Effusion

Effusions Pericardial

The pericardium is a double-layered sac that surrounds the heart; the visceral (that is in contact with the heart) pericardium is a serous membrane that is separated by a small quantity (15–50 mL) of fluid, from the fibrous parietal pericardium. Pericardial effusion is defined as an abnormal accumulation of fluid in this cavity.


Presentation

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]
  • […] 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]
  • […] 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[symptoma.com]
  • 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
  • Aside from pleural effusion and ascites, pericardial effusion is rarely observed in Meigs' syndrome. Here, we report the first case of Meigs' syndrome with preceding pericardial effusion in advance of pleural effusion.[ncbi.nlm.nih.gov]
  • Eosinophilic pleural effusions (EPE) account for 5%-8% of all exudative pleural effusions. A pleural effusion is defined as eosinophilic if it contains 10% or more eosinophils.[ncbi.nlm.nih.gov]
  • KEYWORDS: Acute pancreatitis; pericardial effusion; pleural effusion[ncbi.nlm.nih.gov]
  • This represents a unique presentation of YNS as the first report of a patient with YNS and a pericardial effusion in the absence of pleural effusions and lymphedema and is the 11th case report of YNS with pericardial effusion.[ncbi.nlm.nih.gov]
  • Both the pleural effusion and the pericardial effusion in this patient subsequently improved with the relief of SVC stenosis.[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]
  • 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]
  • A 61-year-old male patient was admitted to our hospital for progressive leg edema, dyspnea on exertion, and lower-extremity muscle weakness. Echocardiography showed a hyperkinetic left ventricle and a moderate amount of pericardial effusion.[ncbi.nlm.nih.gov]
  • In the 6th month of surgery, the patient admitted by dyspnea and massive pericardial effusion that treated by subxiphoid drainage. This event was re occurred in two times in a short time frame and each event treated by surgical approach.[ncbi.nlm.nih.gov]
  • A 73-year-old Asian man who was a former tobacco smoker presented with progressive exertional dyspnea, systemic edema, and pericardial effusion.[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]
  • […] 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]
  • 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]
  • 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.[symptoma.com]
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]
  • It includes difficulty in breathing (dyspnea) on exertion, breathing difficulty on lying down (orthopnea) and palpitations. The lips and skin may show a bluish tinge (cyanosis).[healthhype.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]
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]
  • Forty-eight years old male patient was hospitalized with shortness of breath, chest pain, swelling of the eyelids and bilateral limbs complaints.[ncbi.nlm.nih.gov]
  • 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]
  • […] 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]
  • CAR should be considered as a differential diagnosis in patients with acute chest pain, even in the absence of pericardial effusion, particularly in case of inferior wall involvement.[ncbi.nlm.nih.gov]
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]
  • Despite a relative tachycardia, his observations were otherwise unremarkable. His blood tests revealed a C-reactive protein (CRP) of 86 mg/L and an anti-cyclic citrullinated peptide (anti-CCP) titre of 360 units/mL.[ncbi.nlm.nih.gov]
  • […] mediastinal lymphadenopathy on chest CT scan, increased concentration of tumour markers (cytokeratin 19 fragments-Cyfra 21-1 and carcinoembryonic antigen-CEA) in pf, bloody character of pf, signs of imminent cardiac tamponade on echocardiography and tachycardia[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]
  • 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]
Distended Neck Veins
  • […] tamponade : hypotension , muffled heart sounds , distended neck veins ![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]
  • At the visit she is asymptomatic without evidence of distended neck veins. The ECG shows sinus rhythm with low QRS voltages (Figure 1). Figure 1. Low QRS voltages on ECG.[escardio.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]
  • 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]
Yellow Nails
  • Yellow nail syndrome (YNS) is a constellation of clinical findings including at least 2 of the 3 features of thickened yellow nails, respiratory tract involvement, and lymphedema.[ncbi.nlm.nih.gov]
  • Yellow nail syndrome (YNS) is an uncommon condition characterized by nail changes, lymphedema, in addition to pulmonary disorders and pleural effusion.[ncbi.nlm.nih.gov]

Workup

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]
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]
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]
Toxocara Canis
  • We report here the first case of Toxocara canis-induced eosinophilic fulminant myocarditis which was diagnosed based on eosinophil-rich pericardial effusion where the patient recovered with early corticosteroid therapy. 2015 BMJ Publishing Group Ltd.[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
  • Aside from pleural effusion and ascites, pericardial effusion is rarely observed in Meigs' syndrome. Here, we report the first case of Meigs' syndrome with preceding pericardial effusion in advance of pleural effusion.[ncbi.nlm.nih.gov]
  • Eosinophilic pleural effusions (EPE) account for 5%-8% of all exudative pleural effusions. A pleural effusion is defined as eosinophilic if it contains 10% or more eosinophils.[ncbi.nlm.nih.gov]
  • KEYWORDS: Acute pancreatitis; pericardial effusion; pleural effusion[ncbi.nlm.nih.gov]
  • This represents a unique presentation of YNS as the first report of a patient with YNS and a pericardial effusion in the absence of pleural effusions and lymphedema and is the 11th case report of YNS with pericardial effusion.[ncbi.nlm.nih.gov]
  • Both the pleural effusion and the pericardial effusion in this patient subsequently improved with the relief of SVC stenosis.[ncbi.nlm.nih.gov]

Treatment

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].

Prognosis

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.

Etiology

There are many causes of a possible pericardial effusion.

Epidemiology

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].

Sex distribution
Age distribution

Pathophysiology

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

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)

Summary

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 

Patient Information

  • 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.

References

Article

  1. Spodick DH. The Pericardium: A Comprehensive Textbook, Marcel Dekker, New York 1997. p.260.
  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

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Last updated: 2019-06-28 11:02