Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 10-51: Pericardial Effusion & Tamponade + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ ++ Small effusions can be monitored by careful observations of the JVP and by testing for a change in the paradoxical pulse Serial echocardiograms are indicated if no intervention is immediately contemplated Vasodilators and diuretics should be avoided When tamponade is present, urgent pericardiocentesis or cardiac surgery is required Continued or repeat drainage may be indicated, especially in malignant effusions Pericardial windows via video-assisted thoracoscopy have been effective in preventing recurrences and is more effective than subxiphoid surgical windows or percutaneous balloon pericardiotomy Additional therapy is determined by the nature of the primary process Recurrent effusion in neoplastic disease and uremia, in particular, may require partial pericardiectomy + Outcome Download Section PDF Listen +++ +++ Prognosis ++ The prognosis is a function of the cause Large idiopathic chronic effusions (over 3 months) have a 30–35% risk of progression to cardiac tamponade Presence of pericardial fluid in patients with pulmonary hypertension is a poor prognostic sign +++ When to Refer ++ Any unexplained pericardial effusion should be referred to a cardiologist Trivial pericardial effusions are common, especially in heart failure, and need not be referred unless symptoms of pericarditis are evident A pericardial effusion that hemodynamically compromises the patient (suggested by hypotension or paradoxical pulse) is a medical emergency and requires immediate drainage Any echocardiographic signs of tamponade + References Download Section PDF Listen +++ + +Azarbal A et al. Pericardial effusion. Cardiol Clin. 2017 Nov;35(4):515–24. [PubMed: 29025543] + +Cremer PC et al. Complicated pericarditis: understanding risk factors and pathophysiology to inform imaging and treatment. J Am Coll Cardiol. 2016 Nov 29;68(21):2311–28. [PubMed: 27884251] + +Horr SE et al. Comparison of outcomes of pericardiocentesis versus surgical pericardial window in patients requiring drainage of pericardial effusions. Am J Cardiol. 2017 Sep 1;120(5):883–90. [PubMed: 28739031]