From the Guidelines
The workup for pericardial effusion should begin with a thorough history and physical examination, followed by an electrocardiogram (ECG), chest X-ray, and transthoracic echocardiography, as recommended by the 2015 ESC guidelines 1. The initial evaluation should also include routine blood tests, such as complete blood count, comprehensive metabolic panel, cardiac biomarkers (troponin, BNP), inflammatory markers (ESR, CRP), and thyroid function tests.
- Additional testing may include:
- Blood cultures if infection is suspected
- Tuberculosis testing
- Antinuclear antibodies and rheumatoid factor for autoimmune causes
- CT or MRI for better visualization of the pericardium and adjacent structures
- If the etiology remains unclear or if there is concern for malignancy or infection, pericardiocentesis should be performed for diagnostic purposes, with fluid sent for cell count, culture, cytology, and biochemical analysis, as supported by the 2017 study on cardiovascular complications of cancer therapy 1.
- Pericardial biopsy may be considered in cases where less invasive testing is inconclusive, as stated in the 2015 ESC guidelines 1. The workup should be tailored to the clinical presentation and suspected underlying cause, as pericardial effusions can result from various conditions, including infection, malignancy, autoimmune disorders, metabolic disturbances, trauma, or iatrogenic causes, as discussed in the 2015 ESC guidelines 1 and the 2017 study on cardiovascular complications of cancer therapy 1.
From the Research
Diagnostic Approach
- The diagnosis of pericardial effusion involves a combination of clinical evaluation, imaging techniques, and laboratory tests 2, 3, 4, 5, 6.
- Echocardiography is a crucial tool in diagnosing pericardial effusion, as it helps to define the location and size of the effusion 2, 3, 4, 5, 6.
- Other imaging techniques, such as chest X-ray, electrocardiogram, computed tomography scan, and cardiac magnetic resonance imaging, may also be used to evaluate pericardial effusion 4, 6.
Etiology and Risk Factors
- Pericardial effusion can be caused by various factors, including inflammatory and non-inflammatory etiologies 3, 5, 6.
- The presence of acute inflammatory signs, such as chest pain, fever, and pericardial friction rub, can be predictive of acute idiopathic pericarditis 5.
- Severe effusion with absence of inflammatory signs and absence of tamponade can be predictive of chronic idiopathic pericardial effusion 5.
- Epidemiologic considerations, such as geographic location and underlying diseases, can also play a role in determining the etiology of pericardial effusion 5.
Management and Treatment
- The management of pericardial effusion depends on the presence of hemodynamic compromise, the size of the effusion, and the underlying etiology 2, 3, 5, 6.
- Pericardiocentesis is performed in patients with tamponade, preferably with echocardiographic guidance 2, 3, 6.
- In patients with large effusions but no tamponade, pericardiocentesis is rarely needed for diagnostic purposes, but may be performed if there is concern for a bacterial infection 6.
- Pericardial window is preferred in patients with malignancy due to the risk of recurrence 6.
- Medical treatment of pericardial effusion is mainly dictated by the presence of inflammatory signs and the underlying disease 5.