Pericardial Effusions
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.An abnormal amount or type of fluid within the pericardium of the heart secondary to various etiologies.
B.Can be acute or chronic, pathologic or idiopathic, or symptomatic or asymptomatic.
C.Arise when there is an increase in production or a decrease in drainage of pericardial fluid; both mechanisms lead to an overabundance of fluid within the pericardial space. The excess fluid leads to inflammation and irritation of the pericardium, which is termed pericarditis.
Incidence
A.Data from the Framingham Heart Study (n = 5,652) showed that 6.5% of adults had pericardial effusions from echocardiogram results.
B.Pericardial effusions are common after cardiac bypass and valve replacement procedures (self-limiting).
C.It is common for patients with underlying hematological/oncological malignancies to have malignant pericardial effusions (21%).
1.Lung cancer (37%), breast cancer (22%), and leukemia/lymphoma (17%) are the most common cancers that cause pericardial effusions.
D.Evidence of HIV or AIDS increases the risk of pericardial effusions (prevalence between 5% and 43%, depending on the study’s inclusion criteria).
Pathogenesis
A.The pericardium is a double-walled sac that surrounds the heart. Its two layers work together to evenly distribute pressure and volume forces across the heart, allowing for stretching of the myocardium and uniform contractions. The layers are:
1.Visceral pericardium (closer to the heart): Composed of ultrafiltered plasma (pericardial fluid is thought to come from this layer).
2.Parietal pericardium (farther from the heart): Contributes to diastolic pressure and pressure within the right side of the heart.
B.The pericardium normally contains 15 to 50 mL of pericardial fluid, which is used for lubrication for each of the pericardial layers.
C.Clinical manifestations of pericardial effusions differ based on the rate of accumulation of the fluid. For example:
1.Instant accumulation of less than 80 mL of fluid can cause significant cardiac compromise.
2.Slow accumulation (months-years) requires more than 2 L of fluid before symptoms arise.
3.Acute pericarditis typically involves accumulation of 150 to 200 mL of fluid when symptoms occur.
D.Pericardium has an important role during inspiration.
1.As the right atrium and ventricle fill, the pericardium prevents the left atrium and ventricle from expanding.
2.This process stretches the atrial and ventricular septum, decreases left ventricular filling volumes, and reduces cardiac output.
3.If there is a significant accumulation of fluid within the pericardial space, the pressure within the pericardial spaces increases, stroke volume declines, and life-threatening cardiac tamponade can result.
Predisposing Factors
A.Postprocedures (coronary artery bypass grafting [CABG] or valve replacement).
B.Post-myocardial infarctions (MIs).
C.Neoplastic status.
1.Benign: Atrial myxoma.
2.Primary malignancy: Mesothelioma.
3.Metastatic malignancy: Lung cancer or breast cancer.
4.Hematologic malignancy: Leukemia or lymphoma.
D.Congestive heart failure as a result of rheumatic heart disease, cor pulmonale, or cardiomyopathies.
E.Connective tissue disorders: Rheumatoid arthritis, systemic lupus erythematosus, or scleroderma.
F.Chronic renal disease (secondary to uremia) or nephrotic syndrome.
G.Severe hypothyroidism with myxedema coma.
H.Medications: Procainamide, hydralazine, or status post radiation therapy.
I.Infectious pericarditis (most common is viral).
1.HIV/AIDS: Secondary bacterial infection, opportunistic infections, or Kaposi sarcomas.
2.Viral: Coxsackievirus A and B, adenovirus, influenza, and some forms of hepatitis.
3.Fungal: Candida, histoplasmosis, or coccidioidomycosis.
4.Protozoal.
5.Parasitic.
6.Pyogenic: Streptococci, pneumococci, Neisseria, Legionella, or staphylococci.
7.Tuberculosis.
8.Syphilitic.
J.Trauma (blunt or penetrating).
Subjective Data
A.Common complaints/symptoms.
1.Chest pain/discomfort: Can be relieved by leaning forward and worsened by laying supine (27% of patients).
2.Palpitations.
3.Syncope/lightheadedness.
4.Cough/hoarseness (47% of patients).
5.Dyspnea (78% of patients).
6.Anorexia (90% of patients).
7.Anxiety.
8.Confusion/change in mental status.
B.History of the present illness.
1.Inquire about onset, provoking/alleviating factors, quality, severity, and timing of symptoms.
a.Especially important regarding chest pain and positioning for pericarditis (sitting up/leaning forward improves symptoms while lying flat worsens discomfort).
b.Chest discomfort often described as pleuritic (worse with inspiration) and sharp/stabbing.
2.Discuss past medical history, particularly connective tissue disorders; neoplastic diseases; cardiac comorbidities; and infectious diseases such as HIV/AIDS, tuberculosis, or hepatitis.
C.Family and social history.
1.Review family history for connective tissue disorders, cardiac diseases, neoplastic diseases, or renal failure.
2.Determine use of tobacco, alcohol, or illegal substances.
3.Obtain information regarding medications, especially procainamide or hydralazine.
4.Ensure vaccinations and screenings are current.
a.Influenza vaccine.
b.Tuberculosis purified protein derivative (PPD), HIV/AIDS, and sexually transmitted infection testing (i.e., gonorrhea and syphilis).
c.Cancer screenings.
5.Assess for recent travel to wooded areas (exposure to tick-borne illnesses).
D.Review of systems.
1.General: Fevers, chills, weight changes, appetite changes, or malaise.
2.Cardiac: Chest pain/discomfort, or palpitations.
3.Pulmonary: Shortness of breath, dyspnea, cough, or hoarseness/change in voice quality.
4.Gastrointestinal: Singultus (hiccoughs).
5.Neurological: Syncope, lightheadedness, confusion, or change in mental status.
6.Psychiatric: Anxiety.
Physical Examination
A.Vital signs: Pulse, blood pressure (BP), respirations, temperature, oxygen saturation, and weight.
1.Necessary to assess; possible hypotension, pulsus paradoxus, fever, tachycardia, or tachypnea.
B.General: Variable based on patient status; could be asymptomatic or in hemodynamic compromise if positive cardiac tamponade.
C.Neck: Possible hepatojugular reflux or jugular venous distention (JVD).
D.Pulmonary: Possible tachypnea, decreased breath sounds, Ewart sign (dullness to percussion below left scapula secondary to pericardial fluid near left lung).
E.Cardiac: Possible tachycardia, S1 and S2, murmurs, rubs, extra heart sounds (i.e., S3 and S4), pericardial friction rub, and muffled heart sounds. Also assess for increased JVD, hypotension, and muffled heart sounds (Beck’s Triad) which is hallmark for cardiac tamponade.
F.Peripheral vascular: Possible peripheral edema, decreased pulses, or cyanosis.
G.Gastrointestinal: Possible hepatosplenomegaly.
H.Neurological: Mental status examination (if necessitated by patient status).
Diagnostic Tests
A.ECG (abnormal in 90% of cases).
1.Low-voltage QRS.
2.Diffuse nonspecific ST wave changes (can see T-wave flattening) and/or electrical alternans (electrical alternans is usually a sign of a massive effusion).
B.Echocardiography (imaging test of choice): Used to assess overall cardiac function and amount of pericardial fluid present; can detect as little as 20 mL of fluid.
C.Chest x-ray.
1.Can show a water-bottle shaped cardiac silhouette and/or pericardial fat stripe.
2.Can show an associated pleural effusion.
D.CT or MRI: Can be helpful in some instances for small effusions or loculated effusions.
E.Laboratory studies.
1.Complete metabolic panel: Assess electrolytes and renal function.
2.Complete blood count: Assess for leukocytosis and/or underlying HIV/AIDS or malignant process.
3.Cardiac biomarkers: Can see minimal elevation.
4.Thyroid-stimulating hormone (TSH): Assess for hypothyroidism as a cause for pericardial effusion.
5.Rheumatoid factor and/or antinuclear antibody (ANA): Obtain if concern for underlying rheumatologic etiology.
6.HIV/AIDS screening: Obtain if clinically suggested.
7.Rickettsial antibody tests: Obtain if clinically indicated.
8.Throat swab for influenza and adenovirus virus.
9.Blood cultures: Obtain if febrile and clinically indicated.
10.Tuberculin skin testing: Perform if indicated.
F.Pericardial fluid analysis.
1.Currently under debate: Usually done if poor prognosis, likelihood of purulent effusion, pericardial tamponade, or recurrent and/or large effusions (especially conditions that do not resolve with medical management).
2.Can send fluid for a variety of laboratory studies.
a.Cell count and differential.
b.Protein and lactate dehydrogenase.
c.Glucose.
d.Gram stain.
e.Cultures: Bacterial, fungal, acid-fast stain, and culture.
f.Tumor cytology.
g.Rheumatoid factor and ANA if collagen vascular disease is suspected.
Differential Diagnosis
A.Acute pericarditis.
B.Chronic pericarditis.
C.Myocardial infarction (Dressler syndrome is defined as pericarditis after an MI).
D.Pulmonary embolus.
E.Cardiac tamponade.
F.Constrictive pericarditis.
G.Cardiogenic pulmonary edema.
H.Dilated cardiomyopathy.
Evaluation and Management Plan
A.General plan.
1.Goal is to determine underlying etiology and treat accordingly; also important to determine level of care that patient requires (intensive care, inpatient, or outpatient).
2.If positive cardiac tamponade or significant hemodynamic compromise, ICU admission required.
3.Pericardiocentesis is required if hemodynamically unstable; recommended for large effusions or those secondary to bacterial infections or cancerous processes.
a.This procedure is considered to be diagnostic and therapeutic.
i.Done via open surgical procedure or catheter drainage.
ii.Catheter drainage via fluoroscopy, echocardiography, or CT-guidance is the most common method.
b.Following the procedure, an in-dwelling catheter can be placed to prevent fluid reaccumulation: This is removed or replaced within 72 hours.
c.A sclerosing agent (i.e., tetracycline or bleomycin) within the pericardium can also be used to prevent reaccumulation.
d.Other options to prevent recurrence are surgical intervention (pericardial window, thoracotomy or video-assisted thoracic surgery, or balloon pericardiotomy).
e.If constrictive pericarditis, surgical resection is always indicated.
4.Pharmacologic treatments (see section Pharmacotherapy).
B.Patient/family teaching points.
1.Educate regarding symptoms of cardiac compromise and signs and symptoms of worsening effusions; especially important if patient is treated as outpatient.
2.Educate regarding importance of medication compliance and follow-up visits with provider.
3.Explain to patients that despite proper diagnostic testing, an underlying etiology remains undiscovered in 50% of cases.
C.Pharmacotherapy.
1.Aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs): Can be used for acute idiopathic or viral pericarditis.
a.Aspirin is preferred for post-MI pericarditis.
b.NSAIDs are preferred for viral pericarditis (avoid indomethacin in those with coronary artery disease [CAD]).
2.Colchicine: Can be used for acute pericarditis in combination with aspirin or NSAIDs.
a.Avoid in asymptomatic postoperative pericarditis.
b.Discuss with patients regarding side effects: Most common is diarrhea.
3.Steroids: If used early in acute pericarditis, there is an increased risk of reoccurrence once steroids are tapered.
a.Consider in recurrent disease that is unresponsive to NSAIDs and colchicine.
b.Consider for patients with comorbid connective tissue disorder, uremic pericarditis, or autoreactive pericarditis.
c.Recommend to use for at least 1 month with slow taper.
4.Antibiotics.
a.If purulent pericardial fluid and bacterial infection, combine urgent drainage and aggressive intravenous antibiotics (e.g., vancomycin, ceftriaxone, and ciprofloxacin).
D.Discharge instructions.
1.Educate regarding pericardial effusions and pericarditis.
2.Educate on reasons to return to the ED: Specifically signs of hemodynamic instability, cardiac compromise, or worsening infection (if etiology is bacterial or viral).
3.Educate on importance of medication and clinic follow-up compliance.
Follow-Up
A.Patients will require close monitoring until pericardial effusion and symptoms resolve.
B.Patients should have repeat echocardiography to ensure effusion resolution and no evidence of constrictive pericarditis (usually within 4 weeks of diagnosis).
C.Pericardial effusions usually resolve with treatment and when underlying illness is treated; often reoccur with comorbid conditions such as neoplasms.
Consultation/Referral
A.Consult with cardiologist.
B.Consult with interventional cardiologist (if cardiac catheterization or minimally invasive pericardiocentesis is indicated).
C.Consult with cardiothoracic surgeon (if invasive procedure is required or patient is status post cardiothoracic surgery).
D.Consult with infectious disease specialist (if indicated).
E.Consult with rheumatologist (if indicated).
F.Consult with interventional radiologist (if pericardial drainage procedure via fluoroscopy is indicated).
G.Consult with hematologist/oncologist (if indicated).
Special/Geriatric Considerations
A.It is important to assess the cognitive status and comorbidities of geriatric patients, especially if invasive procedures may be required.
B.Studies have shown that in elderly patients undergoing echocardiography for other purposes, those with incidental small asymptomatic pericardial effusions had a higher mortality than those without effusions.
C.Elderly patients may present with more vague symptoms (generalized malaise, confusion).
D.As with many other diagnoses, elderly patients with pericarditis and pericardial effusions have poorer outcomes as compared to younger patients with the same disease process.
Bibliography
Agabegi, S. S., & Agabegi, E. D. (2008). Step-up to medicine (2nd ed.). Philadelphia, PA: Wolters Kluwer.
Olshaker, J. S. (2014). Cardiovascular emergencies in the elderly. In J. H. Khan, B. G. Magauran Jr., & J. S. Olshaker (Eds.), Geriatric emergency medicine: Principles and practice (pp. 199–206). New York, NY: Cambridge University Press.
Strimel, W. J., Ayub, B., & Contractor, T. (2019, November 28). Pericardial effusion. In T. X. O’Brien (Ed.), Medscape. Retrieved from http://emedicine.medscape.com/article/157325-overview
Usatine, R. P., Smith, M. A., Chumley, H. S., & Mayeaux, E. J., Jr. (2013). Pericardial effusion. In A. Jawaid & J. Delzell, The color atlas of family medicine (2nd ed., pp. 292–296). New York, NY: McGraw-Hill. Retrieved from http://accessmedicine.mhmedical.com/book.aspx?bookID=685