SFGH 2.11 Intern Report Pearls: Pericardial Effusions

Tidbits on Pericardial Effusions

  • Pericardial effusions can be the result almost any pericardial disorder but majority result from one of the following: (note: the following percentages are from a 2003 review by Levy et al. entitled Etiologic diagnosis of 204 pericardial effusions)
    • Acute pericarditis (2/2 viral, bacterial, TB, or idiopathic)
      • Idiopathic = 29% of cases in the review above; infection = 6%
    • Autoimmune diseases = 5%
    • Post-MI/Dressler’s syndrome = 8%
    • Trauma (including 2/2 diagnostic/interventional procedrues)
    • Malignancy (typically from metastatic spread) = 13%
    • Uremia = 6%
  • ECG findings in pericardial effusions
    • Sinus tachycardia
    • Low QRS voltage – total QRS amplitude is < 5mm in limb leads; < 10mm in precordial leads
      • In one prospective study, the low voltage resolved within one week of treatment with either pericardiocentesis or anti-inflammatory medications
    • Electrical alternans – typically most apparent in precordial leads; high specificity for pericardial effusion
  • ECG findings in pericarditis Pericarditis ECG
    • Widespread ST elevations
    • PR depression as compared to ST depression
      • Note: in aVR, there will be reciprocal changes and one will have PR elevation and ST depression (“knuckle sign”)
  • Determination of the etiology of pericardial effusions
    • Important to note that the majority of effusions are idiopathic. In a review of 322 patients with a moderate or large effusion (Clinical Clues to the Causes of Large Pericardial Effusions), the cause of the effusion was secondary to a known medical condition in 60% of patients and the remaining 40% of patients were evaluated and the following results were found:
      • The presence of inflammatory signs (2 or more of the following features – characteristic chest pain, pericardial friction rub, fever > 37, and diffuse ST elevations) was associated with acute idiopathic pericarditis (LR 5.4)
      • A large effusion without inflammatory signs + tamponade was associated with a malignant effusion (LR 2.9)
    • If initial H+P was unrevealing, they recommended the following limited testing/imaging:
      • CBC
      • Chemistry panel for renal function/uremia
      • Thyroid function
      • CXR – if not completed previously
      • Pericardial fluid – sent for cell count with diff, glucose, total protein, LDH, gram stain and cultures (bacterial, fungal)
        • If clinical c/f TB, can send for AFB culture, PCR for Mycobacterium tuberculi, and adenosine deaminase
        • If clinical c/f malignancy, can send for cytology/tumor markers
      • Note: ANA only if young woman with an effusion and acute pericarditis
  • Management of pericardial effusion
    • Patients with effusion + hemodynamic compromise/tampnade –> urgent drainage for therapeutic and diagnostic purpose.
    • Patients with effusion without hemodynamic compromise –> d/w cardiology re: sampling of effusion for diagnostic purposes and need serial TTE (Q5-7 days) for evaluation of the progression/resolution of the effusion.
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