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PATIENT STORY

A 30-year-old woman presented to her family physician with increasing shortness of breath over the past 2 weeks. Two weeks ago she developed a flulike illness and felt like she never recovered. She denied chest pain or edema, did not take any medications, and had not had any recent trauma or surgery. She had a normal examination. Her chest radiograph showed a classic globular heart as demonstrated in Figure 51-1. She had nonspecific ST changes on her ECG. An echocardiogram confirmed pericardial effusion (Figure 51-2). The underlying etiology was not elucidated, but she recovered spontaneously over the next several months.

FIGURE 51-1

Globular cardiac silhouette or classic "water-bottle heart" seen with a pericardial effusion can be difficult to distinguish from cardiomegaly on plain radiographs. (Reproduced with permission from Heidi Chumley, MD.)

FIGURE 51-2

Echocardiogram showing right ventricular (RV) compression from a pericardial effusion (PE). LV, left ventricle; RA, right atrium. (Reproduced with permission from Heidi Chumley, MD.)

INTRODUCTION

Pericardial effusion is an abnormal amount of fluid that may accumulate in the pericardial space. The pericardial space normally contains 15–50 mL of fluid, which serves as lubrication between the visceral and parietal layers of the pericardium. The speed at which a pericardial effusion develops has a great impact on a patient's symptoms. Pericardial effusions are commonly found in the general population, and the incidence increases with age. They can be caused by cardiac disease or surgery, connective tissue disorders, neoplasms, infections, renal disease, hypothyroidism, or medications; however, a cause is identified only 50% of the time. The definitive diagnosis is made by echocardiography.

EPIDEMIOLOGY

  • Six-and-a-half percent of adults (<1% ages 20 to 30 years; 15% older than 80 years of age) had echocardiogram findings consistent with pericardial effusion in a population-based study of 5652 adults and adult family members of participants in the Framingham Heart Study.1

  • Few large studies have characterized the population prevalence of pericardial effusion; however, the available data consistently show that pericardial effusion is more prevalent than is clinically evident.

  • Seventy-seven percent of patients after cardiac surgery for valves or bypass have pericardial effusions, which rarely (<1%) require treatment (Figure 51-3).2

  • Forty percent of healthy pregnant women have small, asymptomatic pericardial effusions in the third trimester.3

FIGURE 51-3

Moderate pericardial effusion is seen as a wide pericardium (arrow). (Reproduced with permission from Heidi Chumley, MD.)

ETIOLOGY AND PATHOPHYSIOLOGY

Pericardial effusion, acute or chronic, occurs when there is increased production or decreased drainage of pericardial fluid allowing accumulation in the pericardial space. The underlying etiology is clinically apparent approximately 25% of the time and can be determined with testing in another 25% of cases, leaving 50% of cases idiopathic.4 Most idiopathic ...

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