What is the management for a patient presenting with dyspnea and chest pain, with a negative troponin, negative CT (Computed Tomography) angiography for pulmonary embolism (PE) but a large pericardial effusion, and a transthoracic echocardiogram (TTE) showing moderate pericardial effusion?

From the Guidelines

The management for a patient with dyspnea and chest pain who has a large pericardial effusion (confirmed by both CT and TTE) with negative troponin and PE studies should focus on treating pericardial effusion and its underlying cause, with initial management including pericardiocentesis to relieve symptoms and prevent cardiac tamponade. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of targeting the etiology of the pericardial effusion as much as possible 1.

Key Considerations

• Pericardiocentesis is recommended for cardiac tamponade, large pericardial effusions (≥ 2cm), or for diagnostic purposes, with the drain left in place for 3–5 days and surgical pericardial window considered if the output drainage is still high 6–7 days after pericardiocentesis 1.
• The pericardial fluid should be sent for chemistry, microbiology, and cytology to determine the etiology of the effusion.
• For inflammatory causes like viral or idiopathic pericarditis, anti-inflammatory therapy with NSAIDs and colchicine is recommended, while corticosteroids may be considered for refractory cases or specific etiologies 1.
• Ongoing monitoring with serial echocardiograms is essential to assess for reaccumulation of fluid and development of constrictive pericarditis as a potential complication.

Treatment Approach

• The treatment approach should be tailored based on the underlying cause, which could include antibiotics for bacterial infections, antituberculosis therapy for TB, or specific treatments for autoimmune conditions, malignancy, or uremia.
• In cases of malignant pericardial effusion, intrapericardial injection of chemotherapeutic agents or bevacizumab may be considered as an alternative treatment option 1.

Important Notes

• Pericardial effusions are more likely to recur with percutaneous pericardiocentesis compared with pericardiotomy, even though there was no difference in length of stay or ICU admission with either approach 1.
• Factors that carry a poorer prognosis for 2-year survival after pericardiocentesis for malignant effusions include age > 65 years, platelet counts < 20,000, lung cancer, presence of malignant cells in the effusion, and drainage duration 1.

From the Research

Management of Pericardial Effusion

The patient presents with dyspnea and chest pain, negative troponin, negative CT angiography for pulmonary embolism, but a large pericardial effusion on CT and moderate pericardial effusion on transthoracic echocardiogram (TTE). The management of this condition involves several key considerations:

• Diagnosis: The diagnosis of pericardial effusion is primarily made through imaging techniques such as echocardiography and CT scans. Echocardiography is particularly useful for assessing the size and hemodynamic impact of the effusion 2, 3.
• Treatment: The treatment of pericardial effusion depends on the underlying cause and the presence of cardiac tamponade. For large pericardial effusions, colchicine may be effective when nonsteroidal anti-inflammatory drugs and/or corticosteroids fail 4.
• Cardiac Tamponade: Cardiac tamponade is a life-threatening condition that requires urgent evacuation of the pericardial effusion. Echocardiography plays a crucial role in diagnosing tamponade and guiding pericardiocentesis 2, 3.
• Pericardiocentesis: Pericardiocentesis is both a diagnostic and therapeutic tool in the management of pericardial effusion. It involves the removal of fluid from the pericardial space to relieve compression on the heart 5, 2.
• Sclerosing Agents: For recurrent pericardial effusions, especially in cases of malignant pericardial effusion, sclerosing agents can be instilled into the pericardium to prevent recurrence 5.
• Individualized Therapy: The therapy for pericardial effusion must be individualized according to the patient's clinical condition and underlying cause. The main goal is to achieve lasting relief from effusion recurrence as quickly and safely as possible 5, 6.

Key Echocardiographic Findings

For the diagnosis of pericardial tamponade, key echocardiographic findings include:

• Pericardial effusion
• Diastolic right ventricular collapse
• Systolic right atrial collapse
• Plethoric inferior vena cava with minimal respiratory variation
• Exaggerated respiratory cycle changes in mitral and tricuspid valve in-flow velocities 3

These findings, along with clinical presentation and history, are crucial for making an accurate diagnosis and determining the appropriate management strategy 3.