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Key Features

Essentials of Diagnosis

  • Pericardial effusion

    • Clinical impact determined by the speed of accumulation

    • May or may not cause pain

  • Tamponade

    • Tachycardia with an elevated jugular venous pressure (JVP) and either hypotension or a paradoxical pulse

    • Low voltage or electrical alternans on ECG

    • Echocardiography is diagnostic

General Considerations

  • Pericardial effusion

    • Can develop during any acute pericarditis process

    • Because the pericardium covers the ascending aorta and arch, aortic dissection and/or rupture can lead to tamponade

    • The speed of accumulation determines the physiologic importance of the effusion

      • Because of pericardial stretch, effusions > 1000 mL that develop slowly may produce no hemodynamic effects

      • Smaller effusions that appear rapidly can cause tamponade due to the curvilinear relationship between the volume of fluid and the intrapericardial pressure

  • Tamponade

    • Characterized by elevated intrapericardial pressure (> 15 mm Hg), which restricts venous return and ventricular filling

    • As a result, the stroke volume and arterial pulse pressure fall, and the heart rate and venous pressure rise

    • Shock and death may result

Clinical Findings

  • Pericardial effusions

    • May be associated with pain if they occur as part of an acute inflammatory process

    • May be painless, which is often the case with neoplastic or uremic effusion

    • Dyspnea and cough are common, especially with tamponade

    • A pericardial friction rub may be present even with large effusions

  • Cardiac tamponade

    • Can be a life-threatening syndrome evidenced by

      • Tachycardia

      • Hypotension

      • Pulsus paradoxicus (defined as a decline of > 10 mm Hg in systolic pressure during inspiration)

      • Raised JVP

      • Muffled heart sounds

      • Decreased ECG voltage or electrical alternans

    • Other symptoms may result from the primary disease

    • Ventricular filling is inhibited throughout diastole

  • Edema or ascites

    • Rarely present in tamponade

    • These signs favor a more chronic process

Diagnosis

Laboratory Findings

  • Laboratory tests tend to reflect the underlying processes

Imaging and Diagnostic Studies

  • Pericardial effusion

    • Chest radiograph can suggest chronic effusion by an enlarged cardiac silhouette with a globular configuration but may appear normal in acute situations

    • The ECG often reveals nonspecific T-wave changes and reduced QRS voltage

      • Electrical alternans is present only occasionally but is pathognomonic and is believed to be due to the heart swinging within the large effusion

    • Echocardiography is the primary method for demonstrating pericardial effusion and is quite sensitive

      • If tamponade is present, the high intrapericardial pressure may collapse lower pressure cardiac structures, such as the RA and RV

  • Cardiac CT and MRI demonstrate pericardial fluid, pericardial thickening, and any associated contiguous lesions within the chest

  • Diagnostic pericardiocentesis or biopsy may be indicated for microbiologic and cytologic studies

    • Pericardial fluid analysis is most useful in excluding a bacterial cause and is occasionally helpful in malignancies

    • A pericardial biopsy may be performed through a small subxiphoid incision or by use of a video-assisted thoracoscopic surgical procedure

Treatment

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