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Diagnosis and Management of Pericardial Effusion Journal of Mind and Medical Sciences Volume 7 Issue 2 Article 4 2020 Diagnosis and management of pericardial effusion Maria Manea UNIVERSITY EMERGENCY CENTRAL MILITARY HOSPITAL, CARDIOLOGY CLINIC, BUCHAREST, ROMANIA Ovidiu Gabriel Bratu CAROL DAVILA UNIVERSITY OF MEDICINE AND PHARMACY, DEPARTMENT OF UROLOGY, UNIVERSITY EMERGENCY CENTRAL MILITARY HOSPITAL, ACADEMY OF ROMANIAN SCIENTISTS, BUCHAREST, ROMANIA Nicolae Bacalbasa CAROL DAVILA UNIVERSITY OF MEDICINE AND PHARMACY, DEPARTMENT OF VISCERAL SURGERY, FUNDENI CLINICAL INSTITUTE, BUCHAREST, ROMANIA Camelia Cristina Diaconu CAROL DAVILA UNIVERSITY OF MEDICINE AND PHARMACY, DEPARTMENT OF INTERNAL MEDICINE, CLINICAL EMERGENCY HOSPITAL OF BUCHAREST, BUCHAREST, ROMANIA Follow this and additional works at: https://scholar.valpo.edu/jmms Part of the Cardiology Commons, and the Critical Care Commons Recommended Citation Manea, Maria; Bratu, Ovidiu Gabriel; Bacalbasa, Nicolae; and Diaconu, Camelia Cristina (2020) "Diagnosis and management of pericardial effusion," Journal of Mind and Medical Sciences: Vol. 7 : Iss. 2 , Article 4. DOI: 10.22543/7674.72.P148155 Available at: https://scholar.valpo.edu/jmms/vol7/iss2/4 This Review Article is brought to you for free and open access by ValpoScholar. It has been accepted for inclusion in Journal of Mind and Medical Sciences by an authorized administrator of ValpoScholar. For more information, please contact a ValpoScholar staff member at [email protected]. Journal of Mind and Medical Sciences https://scholar.valpo.edu/jmms/ https://proscholar.org/jmms/ I S S N : 2 3 9 2 - 7 6 7 4 Diagnosis and management of pericardial effusion Maria Manea1, Ovidiu Gabriel Bratu2, Nicolae Bacalbasa3, Camelia Cristina Diaconu4 1 UNIVERSITY EMERGENCY CENTRAL MILITARY HOSPITAL, CARDIOLOGY CLINIC, BUCHAREST, ROMANIA 2 CAROL DAVILA UNIVERSITY OF MEDICINE AND PHARMACY, DEPARTMENT OF UROLOGY, UNIVERSITY EMERGENCY CENTRAL MILITARY HOSPITAL, ACADEMY OF ROMANIAN SCIENTISTS, BUCHAREST, ROMANIA 3 CAROL DAVILA UNIVERSITY OF MEDICINE AND PHARMACY, DEPARTMENT OF VISCERAL SURGERY, FUNDENI CLINICAL INSTITUTE, BUCHAREST, ROMANIA 4 CAROL DAVILA UNIVERSITY OF MEDICINE AND PHARMACY, DEPARTMENT OF INTERNAL MEDICINE, CLINICAL EMERGENCY HOSPITAL OF BUCHAREST, BUCHAREST, ROMANIA ABSTRACT Pericardial effusion is a common pathology in clinical practice. The etiology Category: Review of pericardial effusion is diverse, from infectious diseases, malignancies, autoimmune diseases, chronic renal failure, to drug-related or after an Received: March 26, 2020 invasive cardiac intervention. Clinical presentation of pericardial effusion is Accepted: June 03, 2020 variable, depending on the volume of the fluid and the rate of accumulation. Keywords: Clinical manifestations are dramatic if the pericardial fluid accumulates rapidly. Classical symptoms in pericardial effusion include pleuritic chest pericardial effusion, cardiac tamponade, pericardial drainage pain associated with dyspnea. In case of cardiac tamponade, orthopnea, *Corresponding author: jugular venous distension, pulsus paradoxus, hypotension, and shock appear. Transthoracic echocardiography is the gold standard investigation for the Camelia C. Diaconu, diagnosis of pericardial effusions. The echocardiographic signs of cardiac Clinical Emergency Hospital of Bucharest, Internal tamponade are represented by the collapse of the right atrium and right Medicine Clinic, Calea Floreasca no. 8, Bucharest, Romania ventricle, respiratory alteration of mitral and tricuspid flow, and changes of E-mail: [email protected] the inferior vena cava. Management of pericardial effusion is guided by several factors, including hemodynamic impact and etiology. Pericardiocentesis guided by echocardiography is a life-saving procedure in cases of large pericardial effusions and cardiac tamponade. This is a review of the diagnosis and treatment of pericardial effusion. Introduction pericardial fluid can be clinically insignificant. The incidence of pericardial diseases is estimated to be 2 cases The pericardium is a double-layered membrane that per 10 000 persons [2]. covers the heart. It consists of a fibrous and a serous layer Pericardial effusion is classified by its onset as acute, and encloses the pericardial cavity, which contains, subacute, or chronic and by its distribution in physiologically, 15-50 mL of pericardial fluid. The circumferential or loculated. Pericardial effusion is pericardium provides mechanical protection of the heart classified also based on hemodynamic impact (with or and against infections. without cardiac tamponade) or by its composition (exudate, Pericarditis is a common pathology, caused by transudate, hemopericardium, pyo-pericardium). inflammation of the pericardium. Usually, pericarditis is Depending on the effusion volume, pericardial effusion can associated with pericardial effusion, by accumulation of be mild, moderate, or large [1]. pericardial fluid that can be serous, hemorrhagic, or purulent, depending on the etiology. Snyder et al observed Discussions that acute pericarditis is reported in 5% of patients presented to the emergency room for chest pain [1]. Etiology of pericardial effusion Cardiac tamponade is a critical condition, that occurs after The etiology of pericardial effusion is varied (Table 1). rapid or excessive accumulation of pericardial fluid, The 2015 European Society of Cardiology Guideline for associated with hemodynamic instability. the management of pericardial effusion classified the The prevalence of pericarditis can be difficult to etiology into infectious and non-infectious [3]. Among estimate because in some cases the accumulation of infectious causes, the most common agents are viruses, To cite this article: Maria Manea, Ovidiu Gabriel Bratu, Nicolae Bacalbasa, Camelia Cristina Diaconu. Diagnosis and management of pericardial effusion. J Mind Med Sci. 2020; 7(2): 148-155. DOI: 10.22543/7674.72.P148155 Diagnosis and management of pericardial effusion such as Coxsackie A and B, echovirus, adenovirus, A review by Mayosi et al in 2005 reported that influenza, and human herpes virus. Bacterial infections that tuberculosis is the most common cause of pericarditis in can lead to pericardial effusion are represented by Coxiella developing countries [5]. Another review reported that the burnetii, meningococcus, pneumococcus, staphylococcus incidence of tuberculous pericarditis is increasing in and streptococcus [4]. Africa, as a result of the HIV epidemic [6]. Table 1. The etiology of pericardial effusion [3,7]. 1.1. Infectious causes of pericardial effusion Enteroviruses (Coxsackie viruses, Echoviruses), Herpes viruses, Epstein-Barr virus, Viral cytomegalovirus, adenoviruses, parvovirus B19 Mycobacterium tuberculosis, Coxiella, Borrelia, pneumococcus, meningococcus, gonococcus, Bacterial streptococcus, Chlamydia, Mycoplasma, Legionella Fungal Histoplasma, Aspergillus, Candida Parasitic Echinococcus, Toxoplasma 1.2. Non-infectious causes of pericardial effusion Systemic autoimmune and auto-inflammatory diseases (systemic lupus erythematosus, Sjogren Autoimmune syndrome, rheumatoid arthritis, systemic vasculitides, sarcoidosis, inflammatory bowel diseases primary tumors (pericardial mesothelioma), secondary metastatic tumors (lung and breast Neoplastic cancer, lymphoma) Metabolic uremia, myxedema Traumatic and direct or indirect thoracic injury, postmyocardial infarction syndrome, post-pericardiotomy iatrogenic syndrome, after iatrogenic cardiac procedures amyloidosis, aortic dissection, pulmonary arterial hypertension, chronic heart failure, partial or Other complete congenital absence of the pericardium procainamide, hydralazine, methyldopa, doxorubicin, 5-fluorouracil, amiodarone, mesalazine, Drug-related bromocriptine Pericardial effusion can be secondary to noninfectious complicated with pericardial hemorrhage diseases, such as autoimmune diseases (systemic lupus (hemopericardium), ventricular wall rupture after acute erythematosus, rheumatoid arthritis, Sjogren syndrome, myocardial infarction, or after invasive cardiac procedures sarcoidosis), primary tumors (pericardial mesothelioma) or [3]. secondary tumors (most common lung cancer and breast Pathophysiology of pericardial effusion cancer, lymphomas and melanoma), acute myocardial The pericardium has the role to provide mechanical infarction (Dressler syndrome), chronic renal failure [8], protection to the heart, to act as a barrier against infections, hypothyroidism (myxedema), mediastinal radiation, direct and to ensure dynamic interactions of the heart chambers. injury (penetrating thoracic injury), drugs (especially The normal pericardium contains 10-50 mL of pericardial procainamide, hydralazine), and after an invasive cardiac fluid, which is an ultrafiltrate of plasma. The interactions procedure (post-pericardiotomy syndrome), or it may have of the pericardium with pleural lymphatics and the hemodynamic causes (heart failure, pulmonary lymphatic drainage of the pericardial fluid to the hypertension) [3]. In a study that enrolled 114 patients with mediastinal and tracheobronchial lymph nodes explain the neoplasia, pericardial diseases were diagnosed in 18% of pathological involvement of the pericardium in pulmonary cases throughout the monitoring period [9]. diseases [9]. In many cases, the etiology of pericarditis is difficult to Depending on the mechanism of appearance, the establish. Multiple studies on this issue have revealed that pericardial effusion can be classified into exudate and the cause of pericarditis is idiopathic
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