Pericardial effusion overview
|
Pericardial effusion Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Pericardial effusion overview On the Web |
|
American Roentgen Ray Society Images of Pericardial effusion overview |
|
Risk calculators and risk factors for Pericardial effusion overview |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Mugilan Poongkunran M.B.B.S [2]
Overview
Pericardial effusion (fluid around the heart) is an abnormal accumulation of fluid in the pericardial cavity. Because of the limited amount of space in the pericardial cavity, fluid accumulation will lead to an increased intrapericardial pressure and this can negatively affect heart function. When there is a pericardial effusion with enough pressure to adversely affect heart function, this is called cardiac tamponade. Pericardial effusion usually results from a disturbed equilibrium between the production and re-absorption of pericardial fluid, or from a structural abnormality that allows fluid to enter the pericardial cavity. Normal levels of pericardial fluid are from 15 to 50 mL.
Classification
Pericardial effusion can be classified broadly into three types, namely transudative, exudative and hemorrhagic. A fluid secreting malignancy could also be the cause of a pericardial effusion.
Pathophysiology
Pericardial effusion usually results from a disturbed equilibrium between the production and reabsorption of pericardial fluid. This can occur in infections and inflammations where there is increased production of pericardial fluid or in malignancy and hypothyroidism where there is inadequate drainage of the fluid.
Causes
Pericardial effusion can be classified into serous, bloody and chylous 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 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 effusion.
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.[1][2]
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
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.
Physical examination
The vital signs of a patient with small pericardial effusion are often normal. Fever suggests an underlying infectious or inflammatory cause, and the presence of a purulent effusion must be ruled out.
Laboratory Findings
Laboratory investigations for pericardial effusion include the leukocyte count, C-reactive protein, and ESR for ruling out inflammatory causes. The cardiac troponin is elevated if there is an injury to the underlying myocardium, a condition termed as myopericarditis. Diagnostic pericardiocentesis and biopsy help in identifying an underlying infectious or malignant process.
Electrocardiogram
The EKG in patients with pericardial effusion may demonstrate low voltages (micro-voltages or short QRS complexes) and electrical alternans.
Chest X Ray
Chest X ray is very less effective to confirm the diagnosis of pericardial effusion unless there is massive effusion.
Computed Tomography
CT is a very effective diagnostic tool in cases of pericardial effusion as it helps us to narrow down on the etiology by determining the amount and nature of the pericardial fluid. CT is very useful especially in identifying hemorrhagic effusions or clots within the pericardium. A pericardial effusion is often incidentally noted on CT scans obtained for other indications.
Magnetic Resonance Imaging
MRI allow assessment of the entire chest and detection of associated abnormalities in the mediastinum, lungs and adjacent structures. MRI also delineate more precisely the spacial distribution of pericardial effusion in complex pericardial collections. It may be very useful in the investigation of the presence and extension of neoplastic disease.
Echocardiography
The role of echocardiography in the evaluation of the patient is to chracterize the presence, size, location, and hemodynamic impact of a pericardial effusion. Echocardiography is not needed to diagnose pericarditis. Echocardiography should be performed if there is a suspicion of tamponade (e.g. distended neck veins, pulsus paradoxus).
References
- ↑ Maisch B, Ristic A, Pankuweit S (2010). "Evaluation and management of pericardial effusion in patients with neoplastic disease". Prog Cardiovasc Dis. 53 (2): 157–63. doi:10.1016/j.pcad.2010.06.003. PMID 20728703.
- ↑ Atar S, Chiu J, Forrester JS, Siegel RJ (1999). "Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s?". Chest. 116 (6): 1564–9. PMID 10593777.