Pericardial effusion overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Abdelrahman Ibrahim Abushouk, MD[2], Mugilan Poongkunran M.B.B.S [3]
Overview
There is limited information about the historical perspective of pericardial effusion. However, percutaneous pericardiocentesis was first described in 1840 by Frank Schuh. By the 20th century, pericardiocentesis became the established technique for diagnosing and treating pericardial effusion. Before echocardiography, surgeons used a blind-subxiphoid approach; however, this was associated with serious organ injuries. However, the introduction of echo-guided pericardiocentesis improved the accuracy and safety of the procedure. The technique has been further refined over the past four decades.Pericardial effusion can be classified according to the nature of pericardial fluid into transudative, exudative, hemorrhagic, and malignant. Further, it can be classified according to the underlying cause into idiopathic, infectious, neoplastic, and post-operative. In addition, Horowitz et al. developed a classification for pericardial effusions based on echocardiographic findings (the degree of separation between the pericardium and epicardium). Pericardial effusion can be classified into serous, bloody and chylous effusions based on the composition of the effusion fluid. Infections and inflammation usually cause serous effusion while bloody effusions are as a result of trauma to the heart. Though iatrogenic causes and infections are the common etiologies, pericardial disease may also be a feature of other disorders such as inflammatory bowel disease. Aortic dissection or free wall rupture should also be considered in patients with unstable hemodynamics and pericardial tamponade.Most pericardial effusions are caused by inflammation of the pericardium, a condition called pericarditis. As the pericardium becomes inflamed, extra fluid is produced, leading to a pericardial effusion. Viral infections are one of the main causes of pericarditis and pericardial effusions. Infections causing pericardial effusions include cytomegalovirus, coxsackie virus, echovirus, and HIV. However, other conditions like injury to the pericardium or heart from a medical procedure, myocardial infarction, uremia, autoimmune disease and cancer should be considered in differential diagnosis of pericardial effusion.The underlying cause of pericardial effusion depend on the region where the patient is living. While malignancy is the most common cause of pericardial effusion in developed countries, infections such as tuberculosis and HIV seems to be the main etiologies of pericardial effusion in developing countries. Patients with uncomplicated pericarditis usually have a self-resolving course within 2 weeks and can be managed on an outpatient basis. However Cardiac tamponade, purulent pericardial effusion, immunocompromised state, history of cancer, dialysis, use of oral anti-coagulation require urgent intervention. The prognosis of pericardial effusion depends on the underlying etiology being especially poor in patients with neoplastic pericardial effusion and very good in idiopathic/viral pericarditis. Pericardial effusion is a relatively common finding and sometimes the clinical picture of the patient leads directly to the cause for pericardial effusion. Mild pericardial effusion is a relatively a common finding, especially in elderly women and they are usually asymptomatic. Common symptoms may include fever, fatigue, muscle aches, shortness of breath, nausea, vomiting, and diarrhea. Large, serious pericardial effusions, or smaller ones that develop quickly, may cause other symptoms that include shortness of breath, palpitations (sensation that the heart is pounding or beating fast), light-headedness , and cool, clammy skin.
Historical Perspective
There is limited information about the historical perspective of pericardial effusion. However, percutaneous pericardiocentesis was first described in 1840 by Frank Schuh. By the 20th century, pericardiocentesis became the established technique for diagnosing and treating pericardial effusion. Before echocardiography, surgeons used a blind-subxiphoid approach; however, this was associated with serious organ injuries. However, the introduction of echo-guided pericardiocentesis improved the accuracy and safety of the procedure. The technique has been further refined over the past four decades.
Classification
Pericardial effusion can be classified according to the nature of pericardial fluid into transudative, exudative, hemorrhagic, and malignant. Further, it can be classified according to the underlying cause into idiopathic, infectious, neoplastic, and post-operative. In addition, Horowitz et al. developed a classification for pericardial effusions based on echocardiographic findings (the degree of separation between the pericardium and epicardium).
Pathophysiology
Causes
Pericardial effusion can be classified into serous, bloody and chylous effusions based on the composition of the effusion fluid. Infections and inflammation usually cause serous effusion while bloody effusions are as a result of trauma to the heart. Though iatrogenic causes and infections are the common etiologies, pericardial disease may also be a feature of other disorders such as inflammatory bowel disease. Aortic dissection or free wall rupture should also be considered in patients with unstable hemodynamics and pericardial tamponade.
Differentiating Pericardial Effusion from Other Diseases
Most pericardial effusions are caused by inflammation of the pericardium, a condition called pericarditis. As the pericardium becomes inflamed, extra fluid is produced, leading to a pericardial effusion. Viral infections are one of the main causes of pericarditis and pericardial effusions. Infections causing pericardial effusions include cytomegalovirus, coxsackie virus, echovirus, and HIV. However, other conditions like injury to the pericardium or heart from a medical procedure, myocardial infarction, uremia, autoimmune disease and cancer should be considered in differential diagnosis of pericardial effusion.
Epidemiology and Demographics
The underlying cause of pericardial effusion depend on the region where the patient is living. While malignancy is the most common cause of pericardial effusion in developed countries, infections such as tuberculosis and HIV seems to be the main etiologies of pericardial effusion in developing countries.
Risk Factors
Screening
There is insufficient evidence to recommend routine screening for pericardial effusion.
Natural History, Complications, and Prognosis
Patients with uncomplicated pericarditis usually have a self-resolving course within 2 weeks and can be managed on an outpatient basis. However Cardiac tamponade, purulent pericardial effusion, immunocompromised state, history of cancer, dialysis, use of oral anti-coagulation require urgent intervention. The prognosis of pericardial effusion depends on the underlying etiology being especially poor in patients with neoplastic pericardial effusion and very good in idiopathic/viral pericarditis.;
Diagnosis
Diagnostic Study of Choice
Pericardial effusion is primarily diagnosed based on the clinical evaluation along with electrocardiographic and chest radiograph findings, which may suggest the presence of a pericardial effusion. Echocardiography must be performed in all patients with possible pericardial effusion. Echocardiography is an excellent method for detection and estimation of the size of pericardial effusions.
History and Symptoms
Pericardial effusion is a relatively common finding and sometimes the clinical picture of the patient leads directly to the cause for pericardial effusion. Mild pericardial effusion is a relatively a common finding, especially in elderly women and they are usually asymptomatic. Common symptoms may include fever, fatigue, muscle aches, shortness of breath, nausea, vomiting, and diarrhea. Large, serious pericardial effusions, or smaller ones that develop quickly, may cause other symptoms that include shortness of breath, palpitations (sensation that the heart is pounding or beating fast), light-headedness , and cool, clammy skin.
Physical Examination
hypotension in cardiac tamponade
Prominent Y descent
Pleural dullness
Decreased breath sounds
Distant heart sounds
Ascites in chronic cases
Ankle edema in chronic cases