Pericardial Effusion

What is pericardial effusion?

Pericardial effusion is a buildup of fluid around the heart muscle. The heart is surrounded by a protective membrane called the pericardium, which is a sac comprised of two layers of tissue with lubricating fluid in between. Pericardial effusion occurs when the amount of fluid is abnormally high.[1][2][3]

Often, pericardial effusion is mild, progresses slowly, does not show any symptoms, and is discovered incidentally as part of a medical check-up. However, if the pericardial effusion develops or progresses rapidly, the pressure it exerts may compromise the functioning of the heart and lead to serious complications – particularly where there is a large amount of fluid.[1][2][3]

Pericardial effusion can result from almost any condition that affects the pericardium, including pericarditis (inflammation of the pericardium); systemic disorders such as hypothyroidism, systemic lupus erythematosus and rheumatoid arthritis; kidney failure and cancer.[1][4] While pericardial effusion can affect people of all ages, the incidence seems to be higher in those over 50.[5] Generally speaking, in younger people the heart is better able to compensate for a progressing effusion.[2]

The prognosis for pericardial effusion depends on the size of the effusion and the underlying cause. Small effusions are quite common and may simply require monitoring by a doctor.[1] Where necessary, treatment for pericardial effusion involves addressing the cause, for example by prescribing antibiotics for a bacterial infection, steroids and other medications for rheumatoid arthritis, or anti-inflammatory medications for pericarditis.[1][6] Large effusions typically indicate a more serious health condition and may require drainage (pericardiocentesis).[1][7] Recovery may take several weeks or months, depending on the severity and cause of the pericardial effusion.[6]

A possible complication of pericardial effusion is cardiac tamponade, which is a medical emergency requiring immediate intervention.[1]

Symptoms of pericardial effusion

Symptoms depend on the size of the effusion and the rate at which it develops. People with small pericardial effusions that have developed slowly may not experience any specific symptoms at all.[1] However, there may be symptoms related to the underlying cause, e.g. fever from pericarditis.

Where present, symptoms of pericardial effusion may include:[1][8]

  • Chest pain, pressure or discomfort (which may be worse when lying flat on the back, and relieved by sitting up and leaning forward)
  • Feeling light-headed or fainting
  • Palpitations
  • Rapid heart beat
  • Shortness of breath or difficulty breathing
  • Cough
  • Difficulty swallowing
  • Hoarseness
  • Anxiety and confusion
  • Hiccups
  • Nausea
  • Feeling of fullness in the abdomen

Pericardial effusion causes

A wide range of health conditions can cause pericardial effusion. These include the following:[1][9]

  • Pericarditis (acute or chronic)
  • Viral infection (e.g. tuberculosis, HIV)
  • Bacterial, fungal or parasitic infection
  • Heart attack
  • Heart surgery
  • Chest trauma
  • Kidney failure or injury
  • Severe untreated hypothyroidism
  • Whipple’s disease
  • Familial Mediterranean fever
  • Cancer
  • Radiation (e.g. radiotherapy)
  • Sarcoidosis (an inflammatory condition that can affect many organs)
  • Autoimmune conditions (e.g. systemic lupus erythematosus and rheumatoid arthritis)
  • Certain medications (e.g. blood pressure and blood clotting medications)

In many cases of pericardial effusion the cause is unknown.

Diagnosis of pericardial effusion

The first step in diagnosing pericardial effusion will be for a doctor to take the affected person’s medical history and perform a physical examination. The doctor will typically measure the individual’s blood pressure and pulse and listen to the heart through a stethoscope for audible signs of fluid buildup.[1][9]

Where the pericardial effusion has developed slowly, symptoms may be absent or minimal. A doctor will usually look for the following:

  • Accelerated pulse
  • Low blood pressure
  • Muted heartbeat (through the stethoscope)

As well as possible signs of chronic heart failure, including:

  • General physical weakness
  • Distended jugular veins (in the neck)
  • Fast or labored (difficult) breathing
  • Buildup of fluid in the abdomen (belly)
  • Swollen legs

Rapid development of low blood pressure, muted heart sounds and distended jugular veins may indicate the life-threatening condition of cardiac tamponade.[1][9]

It is likely that the doctor will request further tests to confirm the diagnosis of pericardial effusion and establish the cause. These may include:[1][9]

  • Blood tests: These can identify infections, autoimmune conditions, thyroid dysfunction, kidney failure and other possible underlying causes of pericardial effusion.
  • Echocardiogram: A heart ultrasound scan will show the size and shape of the heart and whether fluid has accumulated in the pericardium. This type of scan, which is widely available, is particularly important in the diagnosis of pericardial effusion.
  • Electrocardiography (ECG or EKG): This is a test that measures the heart’s electrical activity. Pericardial effusion may cause abnormal patterns to show.
  • Chest X-ray: The heart may appear enlarged where there is significant pericardial effusion. It may have a “water bottle” shape.
  • CT or MRI: Computed tomography (CT) and magnetic resonance imaging (MRI) tests may present a clearer picture of the presence and size of pericardial effusion.
  • Pericardiocentesis: Removal of a small amount of fluid from the pericardium, using a needle, allows for testing for infections (e.g tuberculosis) and tumor markers.

In addition, the doctor may ask for a pericardial biopsy to be performed.[1] In this procedure, a small amount of tissue is removed from the pericardium to test for infection and other possible causes of pericardial effusion.[10]

Pericardial effusion treatment

Treatment of pericardial effusion depends on the cause and severity of the condition. The goals are to reduce symptoms, address the underlying cause, and prevent or manage complications.[1][6]

Treatment may include:[1][2][11]

  • Strategies to reduce symptoms: such as oxygen therapy where circulation is compromised, diuretics (water pills) and other heart failure medication
  • Strategies to treat complications: such as pericardiocentesis where cardiac tamponade is present
  • Strategies to identify and treat the underlying condition: such as pericardiocentesis, pericardial biopsy, antibiotics where a bacterial infection is present, steroids and other medications where rheumatoid arthritis is implicated, and chemotherapy, radiation therapy and other treatments where cancer is the cause

In some cases, surgical treatment may be necessary.

Treating pericarditis (inflammation of the pericardium)

If pericarditis is present, treatment may include NSAIDs and, in certain cases, a course of colchicine – another type of medication that reduces inflammation. Colchicine may improve the prognosis and help prevent pericarditis recurring. If the pericarditis does not respond to treatment, a course of corticosteroids (such as prednisone) may be necessary.[12][13][14] In cases of acute pericarditis caused by myocardial infarction (heart attack), however, corticosteroids cannot be used, as they may negatively affect the healing process.[15]

Pericardiocentesis

Large effusions that persist or are at risk of causing cardiac tamponade may be treated with pericardiocentesis. In this procedure, excess fluid is drained from the pericardium using a needle and catheter (thin tube). The doctor will typically rely on echocardiography (ultrasound) to guide the process.[1][4][8][11]

Pericardiostomy

Where the pericardial effusion is very large and repeated pericardiocentesis has not been effective, surgery may be recommended. The following procedures may be used:

Subxiphoid pericardiostomy: Also called a “pericardial window”, this procedure can be performed under local anesthesia and has a high success rate. The doctor will make an incision under the breastbone and remove a small part of the pericardium to drain the excess fluid.[1][8]

Video-assisted thoracoscopic surgery: This is also known as VATS or thoracoscopy. Although the procedure involves general anesthesia, it is minimally invasive – requiring only small incisions in the chest wall. The doctor will use a tiny camera to view the pericardium and make a more accurate diagnosis, and can then drain excess fluid by creating a small hole in the pericardium (pleuropericardial window).[16][17]

Alternatives to surgery

Where surgery is not recommended, the following interventions may be used:

Percutaneous balloon pericardiotomy: During this procedure, a doctor inserts a needle into the pericardium via the chest wall. The needle is then replaced with a catheter, which has an inflatable balloon at the tip. This balloon is inflated to create a small hole in the pericardium through which excess fluid can be drained. Balloon pericardiotomy is predominantly used for repeated pericardial effusion that is caused by cancer.[1][8][18]

Intrapericardial sclerosis: In this procedure, a medication is administered to the pericardium to treat the effusion. Medications used include the antibiotics tetracycline and doxycycline and the chemotherapy drug cisplatin, among others.[1]

Complications of pericardial effusion

Cardiac tamponade

This is a life-threatening condition that may develop from pericardial effusion. If the fluid exerts pressure on the heart to the extent that its pumping ability is compromised, immediate treatment is required to prevent mortality. Symptoms of cardiac tamponade may develop rapidly (within minutes or hours) and can include:

  • Shortness of breath
  • Weakness and faintness
  • Nausea
  • Palpitations
  • Confusion or loss of consciousness
  • Blurred vision

Cardiac tamponade is treated with emergency pericardiocentesis or surgery. In severe cases, cardiopulmonary resuscitation (CPR) may be required.[1][19][20]

Chronic pericardial effusion

In some cases, large effusions may recur or persist for longer than six months and require ongoing medical treatment.[1] The affected individual may not experience any symptoms or problems. However, because pericardial effusion may lead to cardiac tamponade, going for regular check-ups and ensuring careful management of heart health is critical. The doctor may recommend pericardiocentesis to drain the effusion as a preventative measure.[6] In many cases, however, pericardiocentesis alone may prove inadequate, and a pericardiectomy may also be necessary.[2]

Small pericardial effusions that persist for a long period of time are fairly common, and are not as much of a concern as large effusions.

Pericardial effusion FAQs

Q: Pericardial effusion vs. cardiac tamponade – what is the difference?
A: Pericardial effusion is the term for an accumulation of fluid around the heart. The amount of fluid may be small or large, and the condition is not always serious or life-threatening. Cardiac tamponade is a rare but life-threatening possible complication of pericardial effusion and other heart conditions. Cardiac tamponade is whenfluid exerts pressure on the heart, impeding its ability to pump and sometimes leading to cardiac arrest. Cardiac tamponade may develop very quickly and requires emergency treatment to prevent mortality.[1][21]

Q: Is there a connection between pericardial effusion and cancer?
A: Yes. Cancer may be a cause of pericardial effusion where it has spread to the pericardium. These cases of pericardial effusion are very serious and require urgent medical treatment.[11] The types of cancer that most commonly cause pericardial effusion include lung cancer, breast cancer, leukemia and lymphoma.[22]

Q: Can pericardial effusion be prevented?
A: It is not usually possible to prevent pericardial effusion. However, steps can be taken to prevent the condition becoming more serious or developing into cardiac tamponade. These steps include:[23]

  • Seeking treatment without delay
  • Following the treatment plan (for example, taking medications as prescribed)
  • Listening to a doctor’s advice for ongoing medical care

Other names for pericardial effusion

  • Fluid around the heart

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  14. The BMJ. “Colchicine Reduces Recurrent Pericarditis.” November 22, 2013. Accessed March 16, 2018.

  15. Medscape. “Acute Pericarditis Treatment & Management.” January 25, 2017. Accessed March 16, 2018.

  16. Mayo Clinic. “Video-assisted thoracoscopic surgery (VATS).” October 21, 2016.

  17. John Hopkins Medicine. “Pericardial Window.” Accessed September 20, 2017.

  18. John Hopkins Medicine. “Percutaneous Balloon Pericardiotomy.” Accessed September 20, 2017.

  19. Current Treatment Options in Cardiovascular Medicine. “Pericardial Effusion and Tamponade.” June, 1999. Accessed September 21, 2017.

  20. UpToDate. “Patient education: Pericarditis (Beyond the Basics).” November 13, 2015. Accessed September 21, 2017.

  21. European Society of Cardiology. “Cardiac tamponade: a clinical challenge.” September 27, 2017. Accessed March 19, 2018.

  22. Journal of the American College of Cardiology. “Cardiovascular Complications of Cancer Therapy.” November, 2017. Accessed March 16, 2018.

  23. Wellstar. “Pericardial Effusion Disease.” Accessed September 18, 2017.