Clinical Notes : Cardiovascular Disease

117. Pericardial Effusion

Pericardial Effusion

 

Definitions

Pericardial effusion is the presence of an abnormal amount of fluid and/or an abnormal character to fluid in the pericardial space.

Anatomy and pathophysiology

The pericardium normally contains as much as 20-50 mL of an ultrafiltrate of plasma.

Approximately 90-120 mL of additional pericardial fluid can accumulate rapidly in the pericardium without an increase in pressure. The capacity of the atria and ventricles to fill is mechanically compromised with further fluid accumulation, which can result in marked increases in pericardial pressure, eliciting reduced stroke volume, decreased cardiac output, and hypotension (cardiac tamponade physiology).

The rapidity of fluid accumulation influences the hemodynamic effect.

With slow accumulation of fluid, the pericardium has time to stretch and accomodate the fluid increase so that hemodynamic compromise does not ensue.

Drainage of the pericardium occurs via the thoracic duct and the right lymphatic duct into the right pleural space.

Pericardial physiology includes 3 main functions.

  • First, through its mechanical function, the pericardium promotes cardiac efficiency by limiting acute cardiac dilation, maintaining ventricular compliance with preservation of the Starling curve, and distributing hydrostatic forces.

    • The pericardium also creates a closed chamber with subatmospheric pressure that aids atrial filling and lowers transmural cardiac pressures.

  • Second, through its membranous function, the pericardium shields the heart by reducing external friction and acting as a barrier against extension of infection and malignancy.

  • Third, through its ligamentous function, the pericardium anatomically fixes the heart.

 
 

Etiology

  • Idiopathic

    • In many cases, the underlying cause is not identified. However, this often relates to the lack of extensive diagnostic evaluation

  • Infectious

    • The most common cause of infectious pericarditis and myocarditis is viral.

    • Common etiologic organisms include coxsackievirus A and B, and hepatitis viruses.

    • Other forms of infectious pericarditis include the following:

      • Pyogenic - Pneumococci, streptococci, staphylococci, Neisseria, Legionella species

      • Tuberculous

      • Fungal - Histoplasmosis, coccidioidomycosis, Candida

      • Syphilitic

      • Protozoal

      • Parasitic

    • Human immunodeficiency virus (HIV) infection can lead to pericardial effusion through several mechanisms, including the following:

      • Secondary bacterial infection

      • Opportunistic infection

      • Malignancy (Kaposi sarcoma, lymphoma)

      • "Capillary leak" syndrome, which is associated with effusions in other body cavities

  • Neoplastic

    • Neoplastic disease can involve the pericardium through the following mechanisms:

      • Direct extension from mediastinal structures or the cardiac chamber

      • Retrograde extension from the lymphatic system

      • Hematologic seeding

  • Postoperative/postprocedural

    • Pericardial effusions are common after cardiac surgery.

    • Early chest tube removal following cardiac surgery, around midnight on the day of surgery, may be associated with an increased risk of postoperative pleural and/or pericardial effusions requiring invasive treatment

  • Other

    • Less common causes of pericardial effusion include the following:

      • Uremia

      • Myxedema

      • Severe pulmonary hypertension

      • Radiation therapy

      • Acute myocardial infarction - Including the complication of free wall rupture

      • Aortic dissection - Leading to hemorrhagic effusion from leakage into the pericardial sac

      • Trauma

      • Hyperlipidemia

      • Chylopericardium

      • Familial Mediterranean fever

      • Whipple disease

      • Hypersensitivity or autoimmune related -Systemic lupus erythematosus, [5] rheumatoid arthritis, ankylosing spondylitis, rheumatic fever, scleroderma, sarcoidosis, Wegener granulomatosis

      • Drug associated - Eg, procainamide, hydralazine, isoniazid, minoxidil, phenytoin, anticoagulants, methysergide

 
 
 
 

Epidemiology

  • Incidence of pericardial effusion :

    • Observed in all age groups. The mean occurrence is in the fourth or fifth decades, although it is earlier than this in patients with HIV.. 

Presentation

  • Cardiovascular symptoms :

    • 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 :

    • cough

    • dyspnea

    • hoarseness

  • Neurologic symptoms :

    •  anxiety and confusion

  • Gastrointestinal (GI) symptom.

    • hiccoughs

Diagnosis

  • Cardiovascular findings :

    • Pericardial friction rub

      • Pericardial friction rub, the most important physical sign of acute pericarditis,

      • may have up to 3 components per cardiac cycle

      • is high-pitched, scratching, and grating.

      • It can sometimes be elicited only when firm pressure with the diaphragm of the stethoscope is applied to the chest wall at the left lower sternal border.

      •  is heard most frequently during expiration with the patient upright and leaning forward.

    • Classic Beck triad of pericardial tamponade

      • Hypotension, muffled heart sounds, jugular venous distention

    • Pulsus paradoxus

      • Exaggeration of physiologic respiratory variation in systemic blood pressure, defined as a decrease in systolic blood pressure of more than 10mm Hg with inspiration, signaling falling cardiac output during inspiration

    • Tachycardia

    • Hepatojugular reflux

      • This can be observed by applying pressure to the periumbilical region; a rise in the jugular venous pressure (JVP) of greater than 3 cm H2 O for more than 30 seconds suggests elevated central venous pressure (however, transient elevation in JVP may be normal)

    • Extremities

      • weakened peripheral pulses

      • edema

      • cyanosis

  • Respiratory findings :

    • Pericardial friction rub

      • Tachypnea

      • Decreased breath sounds

        • secondary to pleural effusions 

      • Ewart sign

        • dullness to percussion beneath the angle of left scapula from compression of the left lung by pericardial fluid

  • ECG findings :

    • features of pericarditis​

    • electrical alternans in massive pericardial effusion

 

 

Management :

 

Refer all cases to A+E for further investigation and management

  • Pharmacotherapy

    • Aspirin/NSAIDs

      • Most acute idiopathic or viral pericarditis occurrences are self-limited

      • ibuprofen (300-800 mg q6-8h)

      • aspirin (650 mg q6h)

    • Corticosteroids/NSAIDs

      • in autoimmune conditions.

    • Colchicine

      • in combination with aspirin or NSAIDs or corticosteroid

    • Steroids

      • associated with an increased incidence of relapse after the steroids are tapered

      • used only in patients with :

        • recurrent pericarditis that is unresponsive to NSAIDs and colchicine

        • autoimmune conditions

    • Antibiotics

      • In purulent pericarditis

        • intravenous (IV) (eg, vancomycin 1 g bid, ceftriaxone 1-2 g bid, and ciprofloxacin 400 mg daily)

    • Antineoplastic therapy

      • in conjunction with pericardiocentesis reduces recurrences of malignant effusions

 

  • Pericardiocentesis

    • for diagnostic as well as therapeutic purposes

    • under fluoroscopic, echocardiographic, or CT guidance

  • Pericardiotomy and Pericardiostomy

    • for recurrent effusions

  • Median sternotomy

    • for constrictive pericarditis

 
journals.png

Montaudon M, Roubertie F, Bire F, Laurent F. 

Congenital pericardial defect: report of two cases and literature review.

Surg Radiol Anat. 2007 Apr. 29(3):195-200.

View/Access

Kuvin JT, Harati NA, Pandian NG, Bojar RM, Khabbaz KR.

Postoperative cardiac tamponade in the modern surgical era.
Ann Thorac Surg. 2002 Oct. 74(4):1148-53.

View/Access

Tsang TS, Barnes ME, Hayes SN, et al.

Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and outcomes of echo-guided pericardiocentesis for management:

Mayo Clinic experience, 1979-1998. Chest. 1999 Aug. 116(2):322-31.

View/Access

Ciliberto GR, Anjos MC, Gronda E, et al.

Significance of pericardial effusion after heart transplantation.

Am J Cardiol. 1995 Aug 1. 76(4):297-300.

View/Access

Rosenbaum E, Krebs E, Cohen M, et al.

The spectrum of clinical manifestations, outcome and treatment of pericardial tamponade in patients with systemic lupus erythematosus: a retrospective study and literature review.

Lupus. 2009 Jun. 18(7):608-12

View/Access

Biteker FS, Biteker M, Basaran O, et al.

A small pericardial effusion is a marker of complicated hospitalization in patients with community-acquired pneumonia.

J Crit Care. 2017 Nov 23. 44:294-9.

View/Access

Bussani R, De-Giorgio F, Abbate A, Silvestri F.

Cardiac metastases.

J Clin Pathol. 2007 Jan. 60(1):27-34.

View/Access

Meenakshisundaram R, Sweni S, Thirumalaikolundusubramanian P.

Cardiac isoform of alpha 2 macroglobulin: a marker of cardiac involvement in pediatric HIV and AIDS.

Pediatr Cardiol. 2010 Feb. 31(2):203-7.

View/Access

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. 2011 Nov 10. 16(11):480-3.

View/Access

 

CPD Quiz and Certificate

This activity attracts 1,0 CPD point

Scroll down the box above to view its entire content

All users who successfully complete the quiz are e-mailed a copy of their personalised CPD certificate.