From the Guidelines
The workup of new onset pericardial effusion should begin with a thorough history, physical examination, and basic laboratory tests including complete blood count, comprehensive metabolic panel, cardiac biomarkers, and inflammatory markers (ESR, CRP) 1. The diagnostic approach to new onset pericardial effusion involves several key steps.
- An electrocardiogram should be obtained to assess for electrical alternans or low voltage QRS complexes.
- Echocardiography is the cornerstone diagnostic test, providing information on effusion size, location, hemodynamic significance, and signs of tamponade 1.
- For effusions of unclear etiology, additional testing should include thyroid function tests, tuberculosis screening, HIV testing, and antinuclear antibody testing.
- Chest radiography can help identify cardiomegaly and assess for pulmonary pathology.
- If the effusion is moderate to large or causing hemodynamic compromise, pericardiocentesis should be performed for both therapeutic and diagnostic purposes, with fluid sent for cell count, culture, cytology, and biochemical analysis 1.
- CT or cardiac MRI may be indicated for suspected malignancy or loculated effusions. The underlying cause must be identified and treated specifically, as etiologies range from infection and autoimmune disease to malignancy, uremia, and medication effects.
- Patients with signs of tamponade (hypotension, tachycardia, pulsus paradoxus, jugular venous distention) require urgent intervention regardless of the underlying cause 1. It is essential to note that 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.
From the Research
Diagnostic Approach to New Onset Pericardial Effusion
The diagnostic approach to new onset pericardial effusion involves several steps, including:
- Assessing the size and hemodynamic importance of the effusion 2
- Evaluating for possible associated diseases, such as infections, cancer, and connective tissue diseases 2
- Performing specific testing according to clinical suspicion, including laboratory tests and imaging studies 2
- Considering the presence of elevated inflammatory markers and other criteria, such as chest pain, pericardial rubs, and ECG changes, to suggest pericarditis 2
Role of Imaging in Diagnosis
Imaging plays a crucial role in the diagnosis and management of pericardial effusion, including:
- Echocardiography to assess the size and severity of the effusion 3
- Multimodality imaging to evaluate the hemodynamic impact of the effusion on diastolic filling of the heart 4
- Imaging to detect and diagnose underlying conditions associated with pericardial effusion, such as cancer or connective tissue diseases 5
Management of Pericardial Effusion
The management of pericardial effusion depends on several factors, including:
- The size and duration of the effusion 5, 4
- The presence of hemodynamic compromise or cardiac tamponade 6, 3
- The elevation of inflammatory markers and the presence of underlying conditions associated with pericardial effusion 5, 2
- The patient's symptoms and clinical presentation, with asymptomatic patients potentially being managed conservatively 5, 4