From the Guidelines
The treatment of small chronic pericardial effusion should focus on addressing the underlying cause, and in the absence of inflammation, observation with regular echocardiographic follow-up may be sufficient without specific therapy. According to the 2015 ESC guidelines for the diagnosis and management of pericardial diseases 1, therapy of pericardial effusion should be targeted at the aetiology as much as possible. In about 60% of cases, the effusion is associated with a known disease, and the essential treatment is that of the underlying disease.
When pericardial effusion is associated with pericarditis, management should follow that of pericarditis. However, when a pericardial effusion becomes symptomatic without evidence of inflammation or when empiric anti-inflammatory drugs are not successful, drainage of the effusion should be considered. Pericardiocentesis with prolonged pericardial drainage of up to 30 ml/24 h may be considered in order to promote adherence of pericardial layers and prevent further accumulation of fluid.
Some key points to consider in the treatment of small chronic pericardial effusion include:
- Observation with regular echocardiographic follow-up every 3-6 months may be sufficient for asymptomatic and stable cases
- Targeted treatment is recommended for symptomatic cases or those with identified causes
- Anti-inflammatory medications, such as NSAIDs and colchicine, may be used to reduce inflammation and prevent recurrence
- Corticosteroids may be used for refractory cases or when autoimmune disorders are suspected
- Diuretics, such as furosemide, can help manage symptoms if fluid overload is present
It's worth noting that the 2016 ESC position paper on cancer treatments and cardiovascular toxicity 1 also discusses pericardial disease, but the recommendations for treatment are similar to those in the 2015 ESC guidelines. In general, the treatment approach should prioritize reducing inflammation, promoting reabsorption of existing fluid, and addressing the underlying cause of the effusion.
From the Research
Small Pericardial Effusion Chronic Treatment
- The treatment approach for small pericardial effusion depends on the underlying etiology and clinical presentation 2, 3.
- In cases of asymptomatic or minimally symptomatic chronic large idiopathic pericardial effusions, a conservative approach with watchful waiting seems to be the most reasonable option 3, 4.
- For small chronic idiopathic effusions, the prognosis is excellent and does not require specific monitoring 3.
- The use of non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine may be considered in the treatment of pericarditis, with colchicine continued for at least 3-6 months to reduce the risk of recurrence 5, 6.
- In patients with recurrent pericarditis, interleukin-1 blockers may be used as a third-line option or as second-line therapy after NSAIDs and colchicine in patients with contraindications to glucocorticoids or high-risk features 6.
Treatment Considerations
- The size and location of the pericardial effusion, as well as the presence of comorbidities, will influence clinical decision-making 3.
- Pericardial drainage may be indicated in cases with hemodynamic compromise, either through pericardiocentesis or pericardial "window" 2, 3.
- Analysis of pericardial fluid should be performed in all cases to provide clues to the underlying etiology 2.