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.
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 life-threatening complications – particularly where there is a large amount of fluid.
Pericardial effusion can result from almost any condition that affects the pericardium, including pericarditis; systemic disorders such as hypothyroidism, lupus and rheumatoid arthritis; kidney failure and cancer. While pericardial effusion can affect people of all ages, the incidence seems to be higher in those over 50. Generally speaking, in younger people the heart is better able to compensate for a progressing effusion.
Small effusions are quite common and may be found during a routine medical check-up; these often cause neither symptoms nor problems and may simply require monitoring by a doctor.
The prognosis for pericardial effusion depends on the size of the effusion and the underlying cause. Treatment 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. Large effusions typically indicate a more serious health condition and may require drainage (pericardiocentesis). Recovery may take several weeks or months, depending on the severity and cause of the pericardial effusion.
Possible complications of pericardial effusion include cardiac tamponade, which is a medical emergency requiring immediate intervention.
Symptoms of pericardial effusion
Symptoms depend on the size of the effusion and the pace of its formation. People with small pericardial effusions that have developed slowly may not experience any specific symptoms at all. However, there may be symptoms related to the underlying cause, e.g. fever from pericarditis.
- Chest pain, pressure or discomfort (which may be worse when lying flat on the back, and relieved by sitting up and leaning forward)
- Light-headedness and fainting
- Rapid heart beat
- Shortness of breath or difficulty breathing
- Difficulty swallowing
- Anxiety and confusion
- Feeling of fullness in the abdomen
Pericardial effusion causes
- 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
- Radiation (e.g. radiotherapy)
- Sarcoidosis (inflammation of the organs)
- Autoimmune conditions (e.g. lupus 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. They will typically measure the individual’s blood pressure and pulse and listen to the heart through a stethoscope for audible signs of fluid buildup.
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, muffled heart sounds and distended jugular veins may indicate the life-threatening condition of cardiac tamponade. These symptoms can lead to heart failure, often necessitating cardiopulmonary resuscitation (CPR).
- 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, 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. In this procedure, a small amount of tissue is removed from the pericardium to test for infection and other possible causes of pericardial effusion.
Pericardial effusion treatment
- Strategies to reduce symptoms: Including oxygen therapy where circulation is compromised, diuretics (water pills) and other heart failure medication
- Strategies to treat complications: Including pericardiocentesis where cardiac tamponade is present
- Strategies to identify and treat the underlying condition: Including 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.
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. In cases of acute pericarditis caused by myocardial infarction (heart attack), however, corticosteroids cannot be used, as they may negatively affect the healing process.
Large effusions that persist or are at risk of causing cardiac tamponade may be treated with pericardiocentesis. In this procedure, excess fluid is drained using a needle and catheter. The doctor will typically rely on echocardiography to guide the process.
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.
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 (pleuropericardial window).
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.
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 chemotherapy drug cisplatin, among others.
UpToDate. “Diagnosis and treatment of pericardial effusion.” May 31, 2017. Accessed September 15, 2017. ↩ ↩ ↩ ↩
Korean Circulation Journal. “Pericardial Effusion and Pericardiocentesis: Role of Echocardiography.” November, 2012. Accessed September 15, 2017. ↩ ↩
World Journal of Cardiology. “Diagnosis and management of pericardial effusion.” May, 2011. Accessed September 15, 2017. ↩ ↩ ↩
Heart. “Pericardial disease: what the general cardiologist needs to know.” August, 2007. Accessed September 15, 2017. ↩