Cardiology > Pericardial effusion  

Background 

Pericardial effusion is the accumulation of fluid in the pericardial sac, which may result from inflammatory, infectious, malignant, traumatic, or systemic causes. It can range from small and asymptomatic to large and hemodynamically significant, potentially leading to cardiac tamponade—a life-threatening emergency. 

II) Classification/Types 

By Volume: 

• • Small: <10 mm echo-free space 

• • Moderate: 10–20 mm 

• • Large: >20 mm 

By Duration: 

• • Acute 

• • Subacute 

• • Chronic (>3 months) 

By Composition: 

• • Serous 

• • Serosanguinous 

• • Hemorrhagic 

• • Purulent 

• • Chylous 

By Hemodynamic Consequences: 

• • With tamponade 

• • Without tamponade 

III) Pathophysiology 

Pericardial effusion develops when the rate of fluid accumulation exceeds the pericardium’s ability to absorb it. Causes include increased capillary permeability (inflammation), decreased lymphatic drainage (malignancy), increased hydrostatic pressure (CHF), or trauma. Rapid accumulation—even in small amounts—can cause tamponade, while gradual accumulation may be tolerated in large volumes. 

IV) Epidemiology 

• • Age: Can occur at any age depending on cause 

• • Sex: No consistent predilection 

• • Etiologies vary by region: 

• • Developed countries: Malignancy, idiopathic, uremic 

• • Developing countries: Tuberculosis common 

Etiology

I) Causes 

• • Inflammatory: Acute pericarditis (viral, autoimmune) 

• • Infectious: Tuberculosis, bacterial (purulent), fungal 

• • Neoplastic: Lung cancer, breast cancer, lymphoma, leukemia 

• • Uremic: ESRD with inadequate dialysis 

• • Post-surgical: Postpericardiotomy syndrome 

• • Post-MI: Dressler syndrome 

• • Trauma: Penetrating/blunt chest trauma 

• • Hypothyroidism 

• • Connective tissue disorders: SLE, RA 

• • Radiation-induced 

• • Medications: Hydralazine, isoniazid, procainamide 

II) Risk Factors 

• • Recent cardiac surgery or trauma 

• • Advanced malignancy 

• • Autoimmune disease 

• • Chronic renal failure 

• • History of TB 

• • Infections or immunosuppression 

Clinical Presentation

I) History (Symptoms) 

• • Pleuritic or dull chest pain 

• • Dyspnea, orthopnea 

• • Fatigue 

• • Dysphagia or hoarseness (from large effusion compressing esophagus or recurrent laryngeal nerve) 

• • Cough 

• • Syncope (if tamponade) 

II) Physical Exam (Signs) 

Vital Signs: 

• • Tachycardia 

• • Hypotension (if tamponade) 

Cardiac Exam: 

• • Muffled heart sounds (distant) 

• • Pericardial friction rub (if concurrent pericarditis) 

• • Pulsus paradoxus (>10 mm Hg drop in SBP with inspiration) 

• • Elevated JVP 

Pulmonary Exam: 

• • Dullness at lung bases (if compression atelectasis or pleural effusion) 

Peripheral: 

• • Edema (if associated with CHF or tamponade) 

Differential Diagnosis (DDx)

• • Cardiac tamponade 

• • Acute pericarditis 

• • Heart failure 

• • Pulmonary embolism 

• • Pneumonia with parapneumonic effusion 

• • Pleural effusion 

• • Mediastinal mass 

Diagnostic Tests

Initial Tests 

ECG: 

• • Low voltage QRS 

• • Electrical alternans (alternating QRS amplitude; tamponade) 

• • ST-segment elevation (if pericarditis) 

Chest X-ray: 

• • Enlarged, “water bottle”-shaped cardiac silhouette (large effusion) 

• • Clear lungs unless concurrent pathology 

Echocardiogram (TTE): 

• • Gold standard for diagnosis 

• • Quantifies size and character 

• • Detects signs of tamponade (RA/RV diastolic collapse, IVC dilation) 

Basic Labs: 

• • CBC, CMP 

• • ESR/CRP (inflammatory or infectious cause) 

• • Troponins (rule out MI or perimyocarditis) 

Pericardial Fluid Analysis (if pericardiocentesis done): 

• • Appearance: Clear, bloody, purulent, milky 

• • Cell count and differential 

• • Protein, LDH (Light’s criteria) 

• • Cytology 

• • Gram stain, cultures 

• • AFB stain and TB PCR 

• • Fungal cultures 

Advanced Imaging (if needed): 

CT Chest or Cardiac MRI: 

• • Detect pericardial thickening, masses, or loculated effusions 

Treatment

I) Medical Management 

Asymptomatic or Small Effusion: 

• • Monitor with serial echocardiograms 

• • Treat underlying cause (e.g., dialysis, hypothyroidism, NSAIDs + colchicine for pericarditis) 

Anti-inflammatory Therapy: 

• • NSAIDs: Ibuprofen or aspirin 

• • Colchicine: 0.5–0.6 mg BID or QD for 3 months 

• • Corticosteroids: Only if autoimmune or refractory cases 

II) Interventional/Surgical 

Pericardiocentesis (diagnostic and therapeutic): 

• • Indicated for tamponade or diagnostic uncertainty 

Pericardial Window: 

• • Surgical drainage in recurrent or loculated effusions 

Pericardiectomy: 

• • Rare, reserved for recurrent effusion or constrictive physiology 

Patient Education, Screening, Vaccines

Education: 

• • Educate on signs of worsening (e.g., dyspnea, syncope) 

• • Emphasize adherence to treatment and follow-up imaging 

Lifestyle: 

• • Limit activity if symptomatic 

• • Avoid NSAID overuse 

• • Monitor weight and symptoms 

Vaccinations: 

• • Influenza 

• • Pneumococcal 

• • COVID-19 

Consults/Referrals

• • Cardiology: For tamponade, diagnostic imaging, and follow-up 

• • Cardiothoracic Surgery: For pericardial window or surgical drainage 

• • Infectious Disease: If TB or purulent pericarditis suspected 

• • Oncology: If malignant effusion 

• • Rheumatology: If autoimmune cause 

Follow-Up

• • Echo monitoring: 

• • • Weekly to monthly, depending on size and symptoms 

• • Inflammatory markers: 

• • • Track CRP/ESR if inflammatory or autoimmune cause 

• • Symptom reassessment: 

• • • Monitor for tamponade signs or recurrence 

• • Pericardial fluid cytology or TB workup: 

• • • Repeat if recurrent or unclear etiology 

Prognosis: 

• • Depends on underlying cause 

• • Excellent if treated early and no tamponade 

• • Poorer in malignancy, TB, or delayed intervention