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The Lecturio Medical Concept Library ! Pericardial Effusion and Cardiac Tamponade

Pericardial Effusion and Cardiac Tamponade

Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand;
thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in
decreased cardiac output and cardiac tamponade. Signs and symptoms usually occur in the setting of cardiac tamponade and include
dyspnea, hypotension, muffled heart sounds, jugular venous distension, and pulsus paradoxus. The diagnosis of pericardial effusion is
confirmed with echocardiography. Small effusions in stable patients are treated medically. Larger effusions and cardiac tamponade may
require pericardiocentesis or pericardiotomy.

Last update: April 14, 2021 6:10 am

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Table of Contents
Epidemiology and Etiology
Epidemiology and
Etiology
Definition
Pathophysiology
Pericardial effusion is the accumulation of fluid in the pericardial space.
Clinical Presentation
Cardiac tamponade is the accumulation of pericardial fluid sufficient to impair cardiac filling and cause
Diagnosis hemodynamic compromise. The rate of fluid accumulation, and not necessarily the amount, is most important.
Management
Differential Diagnosis Epidemiology
References Pericardial effusion:
The incidence is unknown.
Has been observed in approximately 3% of autopsy subjects in studies
Share this concept:
Age:
Can occur in all age groups
! " #
Mean: 50–60 years
Cardiac tamponade:
$ " %
Incidence: 2 cases per 10,000 people in the United States
Occurs in approximately 2% of penetrating injuries
More common in boys and men

Etiology
Many conditions are associated with pericardial effusion, including:
Infection:
Viral (most common):
Coxsackievirus group B
Influenza
Echovirus
HIV
EBV
CMV
Parvovirus B19
Varicella
Bacterial:
Staphylococcus aureus
Streptococcus
Neisseria
Legionella
Treponema pallidum
Mycobacterium tuberculosis
Fungal:
Candida
Histoplasmosis
Coccidioidomycosis
Malignancy:
Primary cardiac tumors
Metastatic disease
Trauma
Post-procedural occurrence:
Cardiac surgery (postpericardiotomy syndrome)
Radiation
Autoimmune and connective tissue disease:
Systemic lupus erythematosus
Rheumatoid arthritis
Ankylosing spondylitis
Scleroderma
Sarcoidosis
Sjögren syndrome
Vasculitis
Other medical conditions:
Post-myocardial infarction (Dressler syndrome)
Heart failure
Aortic dissection (type A)
Uremia (chronic renal failure)
Myxedema
Amyloidosis
Can be induced by drugs:
Procainamide
Hydralazine
Isoniazid
Minoxidil
Phenytoin
Anticoagulants
Idiopathic

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1:16 2:27

Pericardial Effusion and Pericardial Effusion and

Cardiac Tamponade: Cardiac Tamponade:
Definition Causes

Pathophysiology

Normal physiology
The pericardial space normally contains a small volume of serous fluid.
Under normal circumstances, the pericardial fluid cushions the heart, provides a low-friction environment, and
allows the heart to move easily.

Pericardial effusion and cardiac tamponade

The pericardium has limited elasticity.
Accumulation of pericardial fluid pressure in the pericardial sac
As pericardial effusion continues to increase compression of the heart:
Diastolic filling venous congestion
Stroke volume
Cardiac output hypotension and obstructive (cardiogenic) shock
HR to maintain cardiac output as a compensatory mechanism
The rate of fluid accumulation is important:
If fluid were to fill the pericardial space rapidly (e.g., chest trauma), as little as 150 mL could lead to
tamponade.
If fluid accumulates slowly, the pericardial sac can stretch to accommodate approximately 2 L of fluid.

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5:55

Pericardial Effusion and

Cardiac Tamponade:
Pathogenesis

Clinical Presentation

Symptoms
Without cardiac tamponade:
Usually no symptoms specific to effusion
Symptoms may be related to the underlying condition (e.g., infection, uremia, autoimmune disease).
Cardiac tamponade:
Dyspnea
Chest pain (pericarditis):
Worse when lying flat
Improves when sitting up
Lightheadedness
Syncope
Palpitations
Hoarseness
Anxiety or confusion
Fatigue
Hiccups

Physical exam
The following may be seen with large pericardial effusions and cardiac tamponade:
Vital signs:
Hypotension
Tachycardia
Cardiovascular:
Pericardial friction rub (pericarditis)
Muffled heart sounds
Jugular venous distension
Hepatojugular reflux
Weakened peripheral pulses
Pulsus paradoxus: a drop in systolic blood pressure of > 10 mm Hg during inspiration
Respiratory:
Ewart’s sign:
Dullness to percussion beneath the angle of the left scapula
Tubular breath sounds
Egophony
Diminished breath sounds (if pleural effusion is present)
Peripheral:
Edema
Cyanosis

Beck’s triad
The triad describes the classic findings in cardiac tamponade:
Hypotension
Jugular venous distension
Muffled heart sounds on auscultation

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2:07 6:27

Pericardial Effusion and Pericardial Effusion and

Cardiac Tamponade: Cardiac Tamponade:
Signs and Symptoms Pulsus Paradoxus

Diagnosis

Imaging
ECG:
Sinus tachycardia
Low voltage of QRS complexes
Diffuse ST elevation with PR depression (pericarditis)
Electrical alternans:
Consecutive QRS complexes that alternate in height
A motion artifact due to the pendular swinging of the heart within the pericardial space
Seen in large pericardial effusion or cardiac tamponade

Electrical alternans pericardial effusion

Electrical alternans on an ECG in a patient with a large pericardial

effusion:
The arrows point to the alternating amplitude of the QRS complex.
Image: “Electrical alternans” by Eric Williams Medical Sciences Complex, The University of the West
Indies, Champs Fleurs, Trinidad and Tobago. License: CC BY 4.0

Chest X-ray:
Might appear normal in conditions with low fluid accumulation
Enlargement of the cardiac silhouette:
Occurs when > 250 mL of fluid has accumulated
Takes on a “water bottle” shape
Lung fields are typically clear.

Cardiomegaly due to pericardial effusion before and after drainage

Cardiomegaly due to pericardial effusion before and after drainage:

(a) Chest X-ray demonstrating cardiomegaly due to the accumulation of pericardial effusion
(b) There is resolution of this cardiomegaly after drainage of the fluid.
Image: “CXR” by Division of Cardiology, Saint Luke’s University Health Network, Bethlehem, PA 18015, USA. License: CC BY 3.0

Echocardiogram:
Diagnostic test of choice
High sensitivity and specificity
Provides hemodynamic information
Pericardial effusion appears as an echolucent space in the pericardial sac.
Cardiac tamponade findings:
Right atrial free-wall collapse during systole
Right ventricle collapse during diastole
Septal bowing
Inferior vena cava dilation without respiratory variation

Echocardiogram showing pericardial effusion

Transthoracic echocardiography showing pericardial effusion (echolucent region around the heart)
Image: “Transthoracic echocardiography” by Department of Internal Medicine, The University of New Mexico, Albuquerque, NM 87106, USA. License: CC BY 4.0

CT and MRI:
Not the diagnostic modalities of choice
May be used if echo imaging is not diagnostic
Can evaluate for pericardial pathology
May be more sensitive for identifying loculated effusions

CT pulmonary embolus showing pericardial effusion

A CT scan demonstrating pericardial effusion, measuring 19.27 mm

Image: “CT pulmonary embolus” by Stanford Hospital and Clinics, Stanford, California. License: CC BY 2.0

Pericardial fluid analysis and pericardial biopsy

Pericardial fluid analysis and pericardial biopsy may be performed to determine the cause of the pericardial
effusion. The following tests may be conducted on the pericardial fluid:
Gram stain and cultures (including fungal)
Cell count with differential
Cytology
Acid-fast bacillus stain and culture
Viral PCR panel

Laboratory evaluation
The following tests may be performed to ascertain the etiology of a pericardial effusion:
CBC with differential
BUN and creatinine
Erythrocyte sedimentation rate and CRP
Troponin
Thyroid-stimulating hormone (TSH)
Rheumatoid factor levels
ANA
Complement levels
Quantiferon-TB assay
HIV serology

Management

Management of pericardial effusion

Depends on the patient’s stability and the underlying cause of effusion
Identify and treat the underlying conditions.
Medical therapy for inflammatory effusions or associated pericarditis:
NSAIDs
Colchicine
Small effusions in a stable patient are usually self resolving no need for any intervention
Pericardial drainage can be considered in:
Large symptomatic effusions
Uncertain etiology

Management of cardiac tamponade

General considerations:
Administer oxygen.
Measures to cardiac output:
IV fluid resuscitation
Inotropic support (e.g., dobutamine)
Pericardiocentesis:
A needle is inserted into the pericardial space.
Fluid is removed to relieve pressure on the heart.
A catheter can be placed for periodic drainage.

Subxiphoid approach for pericardiocentesis

Subxiphoid approach for pericardiocentesis:

This approach allows the drainage of pericardial fluid.
Image by Lecturio.

Surgical management:
Allows for pericardial biopsy
Preferred in traumatic pericardial effusions
Options:
Pericardiotomy
Pericardial window

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3:11

Pericardial Effusion and

Cardiac Tamponade:
Diagnosis and…
Treatment

Differential Diagnosis
Pericarditis: an inflammation of the pericardium resulting from infection, autoimmune disease, radiation,
surgery, myocardial infarction, or cardiac surgery. Patients may have fever, pleuritic chest pain, and a pericardial
rub on cardiac auscultation. The diagnosis is confirmed based on diffuse ST elevation on ECG, and findings of
pericardial thickening and effusion on echocardiography. Management may include NSAIDs, colchicine, and
steroids.
Myocarditis: an inflammatory disease of the myocardium. Myocarditis most often leads to signs and symptoms
of heart failure. The course of myocarditis may vary based on the etiology and the timeline of symptom
progression. The diagnosis is supported by clinical findings, laboratory evaluation, and cardiac imaging. A
definitive diagnosis using endomyocardial biopsy is rarely required. Management is supportive and aimed at
addressing complications.
Pulmonary embolism: an obstruction of the pulmonary arteries, most often due to thrombus migration from the
deep venous system. Signs and symptoms include pleuritic chest pain, dyspnea, tachypnea, and tachycardia.
Severe cases can result in hemodynamic instability or cardiopulmonary arrest. A chest CT with angiography is
the primary method of diagnosis. Management includes oxygenation, anticoagulation, and thrombolytic therapy
for unstable patients.
Pneumothorax: a life-threatening condition in which air collects in the pleural space, causing a partial or
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complete collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a