From the Guidelines
Pericardial effusion is a medical emergency that requires immediate attention, and the most concerning red flags include chest pain, shortness of breath, rapid or irregular heartbeat, and a feeling of fullness in the chest, particularly in patients with risk factors such as cancer, kidney failure, or autoimmune disorders. The diagnosis of pericardial effusion is based on clinical presentation, electrocardiogram, echocardiography, and chest X-ray, and the presence of red flags such as fever, subacute course, large pericardial effusion, cardiac tamponade, and failure of aspirin or NSAIDs indicates a high-risk patient who requires hospitalization and a full aetiological search 1.
Red Flags of Pericardial Effusion
The red flags of pericardial effusion include:
- Chest pain that worsens when lying down and improves when leaning forward
- Unexplained shortness of breath or dyspnea
- Rapid or irregular heartbeat
- Feeling of fullness in the chest
- Muffled heart sounds (detected during auscultation)
- Distended neck veins
- Swelling in the abdomen or legs
- Low blood pressure
- Beck's triad—hypotension, jugular venous distention, and muffled heart sounds
Diagnosis and Management
The diagnosis of pericardial effusion is based on clinical presentation, electrocardiogram, echocardiography, and chest X-ray, and the management includes pericardiocentesis or surgical drainage for cardiac tamponade or suspected bacterial and neoplastic pericarditis 1. Pericardiocentesis should be performed by experienced operators and carries a risk of complications ranging from 4 to 10% depending on the type of monitoring, the skill of the operator, and the setting 1.
High-Risk Patients
High-risk patients are defined as those with predictors of poor prognosis, including fever, subacute course, large pericardial effusion, cardiac tamponade, and failure of aspirin or NSAIDs, and these patients require hospitalization and a full aetiological search 1. The presence of red flags such as cancer, kidney failure, or autoimmune disorders also indicates a high-risk patient who requires immediate evaluation and management 1.
Recent Guidelines
Recent guidelines recommend that pericardiocentesis or surgical drainage should be performed for cardiac tamponade or suspected bacterial and neoplastic pericarditis, and that percutaneous or surgical pericardial biopsy may be considered in selected cases of suspected neoplastic or tuberculous pericarditis 1. The guidelines also recommend that CT and/or CMR should be used as second-level testing for diagnostic workup in pericarditis 1.
Conclusion is not allowed, so the answer will be ended here.
From the Research
Red Flags of Pericardial Effusion
The following are red flags of pericardial effusion:
- Hypotension 2
- Increased jugular venous pressure 2
- Distant heart sounds (Beck triad) 2
- Dyspnoea progressing to orthopnoea (with no rales on lung auscultation) 2
- Weakness, fatigue, tachycardia, and oliguria 2
- Fever and typical chest pain increasing on inspiration and radiating to the trapezius ridge in tamponade caused by acute pericarditis 2
- Severe effusion with absence of inflammatory signs and absence of tamponade, predictive for chronic idiopathic pericardial effusion 3
- Tamponade without inflammatory signs, predictive for neoplastic pericardial effusion 3
- Acute inflammatory signs (chest pain, fever, pericardial friction rub) predictive for acute idiopathic pericarditis 3
Clinical Findings and Diagnosis
Clinical findings and diagnosis of pericardial effusion include:
- Echocardiography as the first-line diagnostic tool 2, 4, 3
- Multimodality imaging for niche functions 4
- Chest X-ray, electrocardiogram, computed tomography scan, cardiac magnetic resonance imaging, and pericardiocentesis as other imaging techniques 5
- Medical treatment mainly dictated by the presence of inflammatory signs and by the underlying disease if present 3
- Pericardial drainage mandatory when clinical tamponade is present 3
Treatment and Management
Treatment and management options for pericardial effusion include:
- Pericardiocentesis 2, 3, 5
- Pericardial window 6, 5
- Sclerosing therapies 5
- Extended indwelling pericardial catheter, percutaneous pericardiostomy, and intrapericardial instillation of antineoplastic and sclerosing agents for neoplastic pericardial effusion 3
- Wide anterior pericardiectomy for massive chronic idiopathic pericardial effusions 3