What is the initial workup and management for a patient with a new onset large pericardial effusion?

From the Guidelines

The initial workup for a new onset large pericardial effusion should include a thorough history and physical examination, followed by an ECG, chest X-ray, and echocardiogram to confirm the diagnosis and assess hemodynamic significance, as recommended by the 2015 ESC guidelines 1. The management of a new onset large pericardial effusion depends on the underlying etiology and hemodynamic stability of the patient.

• For hemodynamically unstable patients with cardiac tamponade, immediate pericardiocentesis is indicated, as it is a life-saving procedure that can relieve the pressure on the heart and restore cardiac output 1.
• For stable patients, treatment targets the underlying cause while providing supportive care.
• If inflammatory or idiopathic pericarditis is suspected, NSAIDs (ibuprofen 600-800mg three times daily or indomethacin 25-50mg three times daily) for 1-2 weeks with colchicine (0.5mg twice daily for patients >70kg or 0.5mg once daily for patients <70kg) for 3-6 months is recommended, as this combination has been shown to improve outcomes and reduce recurrence rates 1.
• Corticosteroids (prednisone 0.25-0.5mg/kg/day) may be considered for refractory cases or specific etiologies, such as autoimmune disorders or malignancy 1.
• Pericardial fluid should be sent for cell count, protein, LDH, glucose, cytology, and microbiologic studies to help determine the cause of the effusion, as this information can guide further management and treatment 1. Some key points to consider in the management of pericardial effusion include:
• The use of pericardiocentesis with prolonged pericardial drainage may be considered to promote adherence of pericardial layers and prevent further accumulation of fluid, although evidence for this indication is based on case reports and expert opinion 1.
• Pericardiectomy or less invasive options, such as pericardial window, may be considered for recurrent or loculated effusions, or when biopsy material is required 1.
• The role of medical therapies, such as NSAIDs, colchicine, and corticosteroids, in reducing isolated effusions is limited, and pericardiocentesis alone may be necessary for resolution of large effusions 1. Close follow-up with serial echocardiograms is essential to monitor for recurrence or progression to constrictive pericarditis, as this can help identify potential complications early and guide further management 1.

From the Research

Initial Workup for New Onset Large Pericardial Effusion

• The first step in the workup of a new onset large pericardial effusion is to assess its size, hemodynamic importance, and possible associated diseases 2.
• Echocardiography is the diagnostic method of choice due to its portability and wide availability, and it is used to evaluate the size and hemodynamic impact of the effusion on heart diastolic function 3, 4.
• Advanced imaging, including computed tomography and cardiac magnetic resonance imaging, may be performed if baseline tests are inconclusive 4.

Evaluation of Hemodynamic Compromise

• The presence of hemodynamic compromise, such as elevated jugular venous pressure, hypotension, tachycardia, and pulsus paradoxus, should be evaluated 3.
• Echocardiographic clues to tamponade, including diastolic chamber collapse, Doppler flow velocity paradoxus, and inferior vena cava phlethora, should also be assessed 3.

Laboratory Tests and Specific Testing

• Laboratory tests, such as C-reactive protein serum level measurement, should be performed to evaluate for inflammation and possible underlying conditions 4.
• Specific testing should be performed according to clinical suspicion, such as testing for infections (viral, bacterial, especially tuberculosis), cancer, connective tissue diseases, pericardial injury syndromes, metabolic causes (i.e. hypothyroidism), myopericardial and aortic diseases 2, 5.

Management and Treatment

• Treatment should be targeted at the etiology as much as possible, and empiric anti-inflammatory therapy may be worthwhile if the diagnosis is still unclear or idiopathic 2.
• Pericardiocentesis alone may be curative for large effusions, but recurrences are common and pericardiectomy or less invasive options (i.e. pericardial window) should be considered whenever fluid re-accumulates (especially with tamponade), becomes loculated, or biopsy material is required 3, 2, 6.
• A watchful waiting strategy may be reasonable and cost-effective for patients with idiopathic, chronic (> 3 months), large (> 2 cm), asymptomatic pericardial effusions 4.