What are the causes of pericardial effusion?

From the Guidelines

Pericardial effusion is caused by a variety of conditions, including infections, autoimmune disorders, malignancies, metabolic disorders, iatrogenic causes, trauma, and idiopathic pericarditis, as well as certain medications and chemotherapy agents, as reported in the 2015 ESC guidelines for the diagnosis and management of pericardial diseases 1.

Causes of Pericardial Effusion

The causes of pericardial effusion can be categorized into several groups, including:

• Infections (viral, bacterial, fungal, or tuberculous)
• Autoimmune disorders (such as lupus, rheumatoid arthritis, and scleroderma)
• Malignancies (lung cancer, breast cancer, lymphoma, leukemia)
• Metabolic disorders (hypothyroidism, uremia from kidney failure)
• Iatrogenic causes (medication reactions, radiation therapy, post-cardiac surgery)
• Trauma (chest injury, aortic dissection)
• Idiopathic pericarditis

Pathophysiology and Management

The pathophysiology of pericardial effusion involves inflammation of the pericardium, causing increased production of pericardial fluid, decreased reabsorption, or direct leakage of fluid into the pericardial space, as described in the study published in the Journal of the American College of Cardiology in 2017 1. Management depends on identifying and treating the underlying cause while monitoring for signs of hemodynamic compromise that would require drainage procedures.

Diagnosis and Treatment

Diagnosis of pericardial effusion is typically made using echocardiography, and treatment may involve pericardiocentesis, intrapericardial injection of chemotherapeutic agents, or surgical pericardial window creation, as recommended in the 2015 ESC guidelines for the diagnosis and management of pericardial diseases 1.

Prognosis and Recurrence

The prognosis and risk of recurrence of pericardial effusion depend on the underlying cause, with malignant effusions having a poorer prognosis, as reported in the study published in the Journal of the American College of Cardiology in 2017 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, as described in the study published in the Journal of the American College of Cardiology in 2017 1.

From the Research

Causes of Pericardial Effusion

• Inflammatory causes:
  • Idiopathic pericarditis 2, 3
  • Viral pericarditis 3
  • Tuberculous pericarditis, especially in developing countries 2, 4, 3
• Non-inflammatory causes:
  • Cancer, including lung cancer, breast cancer, melanoma, and lymphoma 2, 4, 3, 5
  • Systemic inflammatory diseases 4
  • Autoimmune and autoinflammatory diseases 3
  • Pericardial injury syndromes 3
  • End-stage renal disease 2
  • Acute myocardial infarction 2
  • Cardiac surgery 2
  • Widespread metastatic neoplasm 2
  • Radiation therapy 5
  • Immune checkpoint inhibitors 5
  • Bacterial infections, such as purulent pericarditis 2, 6

Specific Causes

• Neoplastic pericardial effusion: caused by localization of cancer to the pericardium via direct invasion, lymphatic dissemination, or hematogenous spread 5
• Idiopathic pericardial effusion: often seen in developed countries, with no obvious cause apparent 2
• Chronic idiopathic pericardial effusion: characterized by severe effusion with absence of inflammatory signs and absence of tamponade 2

Geographic and Epidemiologic Considerations

• In developed countries, acute idiopathic pericarditis and idiopathic pericardial effusion are the most common etiologies 2
• In underdeveloped geographic areas, tuberculous pericarditis is the leading cause of pericardial effusion 2, 4, 3