What is the treatment for pericardial effusion?

Treatment of Pericardial Effusion

Immediate Management: Cardiac Tamponade

Pericardiocentesis is mandatory for cardiac tamponade regardless of etiology and represents an absolute Class I indication that takes priority over all other considerations. 1

• Use echocardiographic or fluoroscopic guidance during pericardiocentesis to minimize complications including myocardial laceration, pneumothorax, and mortality 1
• Patients with dehydration and hypovolemia may temporarily improve with intravenous fluids while preparing for drainage, but this should not delay definitive intervention 1
• Drain fluid in less than 1-liter increments to avoid acute right ventricular dilatation 1

Critical Contraindication

• Never perform pericardiocentesis in aortic dissection with hemopericardium due to risk of intensified bleeding and extension of the dissection; surgery should be performed immediately instead 2, 1

Treatment Algorithm for Non-Tamponade Effusions

Step 1: Assess for Associated Inflammation

For pericardial effusion with associated inflammation/pericarditis (elevated inflammatory markers, chest pain, pericardial rubs, ECG changes):

• First-line therapy: NSAIDs plus colchicine 1, 3

  • Aspirin 750-1000 mg three times daily OR ibuprofen 600 mg three times daily 1
  • Colchicine 0.5 mg once or twice daily 1
  • For post-myocardial infarction pericarditis, aspirin is the preferred NSAID over other NSAIDs which risk thinning the infarction zone 2, 1

• Second-line therapy: Corticosteroids for patients with contraindications to or failure of first-line therapy 1, 3

  • Corticosteroids should be tapered over a three-month period 1
  • Corticosteroids are reserved for second-line treatment due to higher recurrence rates 1

• Treatment duration should be at least 3 months with gradual tapering 1

Step 2: Etiology-Specific Management

Tuberculous Pericarditis

• Standard anti-TB drugs for 6 months are required to prevent tuberculous pericardial constriction 1, 3
• Empiric anti-TB chemotherapy should be initiated for exudative pericardial effusion after excluding other causes in endemic areas 1

Malignant Pericardial Effusion

• Systemic antineoplastic treatment is the baseline therapy for confirmed malignant effusions and can prevent recurrences in up to 67% of cases 2, 1
• Pericardial drainage is recommended in all patients with large effusions (40-70%) due to high recurrence rates 2, 1
• Intrapericardial instillation of cytostatic/sclerosing agents should be considered to prevent recurrences 2, 1
  • Cisplatin is most effective for lung cancer pericardial involvement (93% and 83% free of recurrence at 3 and 6 months respectively) 2, 1
  • Thiotepa is more effective for breast cancer pericardial metastases 2, 1
  • Tetracyclines as sclerosing agents control malignant effusion in 85% of cases, but side effects are frequent: fever (19%), chest pain (20%), and atrial arrhythmias (10%) 2, 1
• Radiation therapy is very effective (93%) for radiosensitive tumors such as lymphomas and leukemias 1

Purulent/Bacterial Pericarditis

• Aggressive intravenous antibiotic therapy must be initiated immediately and continued throughout the drainage period 1
• Empiric antibiotic regimens should include coverage for Staphylococcus, Streptococcus, Haemophilus, and gram-negatives before microbiological results are available 1
• Surgical drainage is preferred over prolonged catheter drainage in purulent pericarditis 1

Fungal Pericarditis

• Antifungal treatment is indicated for confirmed or suspected fungal pericarditis, particularly in immunocompromised patients 1, 4
• Options include fluconazole, ketoconazole, itraconazole, or amphotericin B formulations 1, 4

Pericardial Drain Management

The pericardial drain should be left in place for 3-5 days and continued until drainage falls below 25 mL per 24-hour period. 1

• Monitor drain output every 4-6 hours 1
• If drainage output remains high (>25 mL/day) at 6-7 days post-pericardiocentesis, surgical pericardial window should be considered 1
• For malignant effusions, consider intrapericardial instillation of chemotherapeutic agents through the drain before removal 1

Antibiotic Coverage

• Routine prophylactic antibiotics are NOT recommended for pericardial drainage procedures or while drains remain in situ for non-infectious etiologies 1
• Antibiotics are only indicated when purulent or bacterial pericarditis is suspected or confirmed 1

Surgical Options for Recurrent or Refractory Effusions

• Percutaneous balloon pericardiotomy is effective (90-97%) and safe for large malignant effusions with recurrent tamponade, creating pleuropericardial communication for fluid drainage 1, 3
• Pericardial window creation via left minithoracotomy is safe and effective for malignant cardiac tamponade 1, 3
• Pericardiectomy is indicated only for frequent and highly symptomatic recurrences resistant to medical treatment, pericardial constriction, or complications of previous procedures 1, 3

Monitoring and Follow-Up Strategy

Small Asymptomatic Effusions

• Generally have good prognosis and may not require specific monitoring 3, 4

Moderate Idiopathic Effusions

• Echocardiographic follow-up every 6 months 1, 3, 4

Large Chronic Effusions (>3 months)

• Carry a 30-35% risk of progression to cardiac tamponade and require more vigilant monitoring every 3-6 months 1, 3, 4
• Follow-up should be based on evaluation of symptoms, echocardiographic assessment of effusion size, and monitoring of inflammatory markers 4

Critical Pitfalls to Avoid

• Anticoagulation should not be used in the setting of iatrogenic pericardial effusion, as it increases risk of tamponade 1
• Patients should be on a steroid-free regimen for several weeks before any surgical intervention 1
• Relative contraindications to pericardiocentesis include uncorrected coagulopathy, anticoagulant therapy, thrombocytopenia <50,000/mm³, and small posterior or loculated effusions 1