What is the diagnosis and treatment for pericardial effusion?

From the Guidelines

Pericardial effusion is diagnosed using echocardiography and treated with pericardiocentesis, with the goal of relieving symptoms and preventing cardiac tamponade.

Diagnosis

• Echocardiography is the first-line imaging test for diagnosing pericardial effusion and cardiac tamponade 1
• The size of the pericardial effusion is qualitatively assessed by the end-diastolic distance of the echo-free space between the epicardium and parietal pericardium: small (<10 mm), moderate (10–20 mm), large (>20 mm) 1
• Clinical signs of cardiac tamponade include tachycardia, hypotension, pulsus paradoxus, raised jugular venous pressure, muffled heart sounds, and decreased electrocardiographic voltage with electrical alternans 1

Treatment

• Pericardiocentesis is a life-saving procedure in cardiac tamponade and is indicated in effusions >20 mm in echocardiography (diastole) 1
• Pericardiocentesis guided by fluoroscopy or echocardiography is performed to drain the pericardial fluid, with the goal of relieving symptoms and preventing cardiac tamponade 1
• Systemic antineoplastic treatment is recommended as baseline therapy for neoplastic pericardial effusion, with pericardiocentesis and intrapericardial instillation of cytostatic/sclerosing agents as additional treatments 1
• Pericardial drainage is recommended in all patients with large (40–70%) effusions, with the goal of preventing recurrences and cardiac tamponade 1

Important Considerations

• The treatment of pericardial effusion should be targeted at the underlying cause, with empiric anti-inflammatory drugs and pericardiocentesis used as needed 1
• Pericardiocentesis is generally safe, with a low incidence of major complications, including laceration and perforation of the myocardium and coronary vessels, air embolism, pneumothorax, and arrhythmias 1

From the Research

Diagnosis of Pericardial Effusion

• Pericardial effusion is diagnosed using various imaging techniques, including chest X-ray, electrocardiogram, transthoracic echocardiography, computed tomography scan, cardiac magnetic resonance imaging, and pericardiocentesis 2
• Echocardiography is a key tool in diagnosing pericardial effusion and assessing its hemodynamic impact 3, 4
• A thorough history and physical examination can help reveal the etiology of pericardial effusion in most patients 5

Treatment of Pericardial Effusion

• The treatment of pericardial effusion depends on the presence or absence of hemodynamic impairment, elevation of inflammatory markers, presence of a known or first-diagnosed underlying condition, and duration and size of the effusion 6
• A 4-step treatment algorithm is suggested by current guidelines, which includes a tailored approach to each patient's condition 6
• For asymptomatic patients with large, chronic, and idiopathic pericardial effusion, a conservative approach may be the most reasonable option 6
• Pericardiocentesis is a definitive treatment for patients with actual or impending tamponade, and should not be delayed for medical treatment 5
• Various invasive and non-invasive strategies, such as pericardiocentesis, pericardial window, and sclerosing therapies, are available for the management of patients with pericardial effusion 2