Pericardial Effusion Clinical Presentation

  • Author: William J Strimel, DO; Chief Editor: Joseph L Fredi, MD   more...
 
Updated: Jun 30, 2010
 

History

A patient with pericardial effusion may report the following symptoms:

  • Cardiovascular
    • Chest pain, pressure, discomfort: Characteristically, pericardial pain may be relieved by sitting up and leaning forward and is intensified by lying supine.
    • Light-headedness, syncope
    • Palpitations
  • Respiratory
    • Cough
    • Dyspnea
    • Hoarseness
  • Gastrointestinal
    • Hiccoughs
  • Neurologic
    • Anxiety
    • Confusion
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Physical

Upon examination, a patient with pericardial effusion may have the following signs:

  • Cardiovascular
    • Classic Beck triad of pericardial tamponade (hypotension, muffled heart sounds, jugular venous distension).
    • Pulsus paradoxus: Exaggeration of physiologic respiratory variation in systemic blood pressure, defined as a decrease in systolic blood pressure of more than 10 mm Hg with inspiration, signaling falling cardiac output during inspiration.
    • Pericardial friction rub: The most important physical sign of acute pericarditis may have up to 3 components per cardiac cycle and is high-pitched, scratching, and grating. It can sometimes be elicited only when firm pressure with the diaphragm of the stethoscope is applied to the chest wall at the left lower sternal border. The pericardial friction rub is heard most frequently during expiration with the patient upright and leaning forward.
    • Tachycardia
    • Hepatojugular reflux: This can be observed by applying pressure to the periumbilical region. A rise in the jugular venous pressure (JVP) of greater than 3 cm H2 O for more than 30 seconds suggests elevated central venous pressure. Transient elevation in JVP may be normal.
  • Respiratory
    • Tachypnea
    • Decreased breath sounds (secondary to pleural effusions)[4]
    • Ewart sign - Dullness to percussion beneath the angle of left scapula from compression of the left lung by pericardial fluid
  • Gastrointestinal - Hepatosplenomegaly
  • Extremities
    • Weakened peripheral pulses
    • Edema
    • Cyanosis
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Causes

In up to 60% of cases, pericardial effusion is related to a known or suspected underlying process. Therefore, the diagnostic approach should give strong consideration to coexisting medical conditions.

  • Idiopathic: In many cases, the underlying cause is not identified. However, this often relates to the lack of extensive diagnostic evaluation.
  • Infectious
    • HIV infection can lead to pericardial effusion through several mechanisms, including the following:
      • Secondary bacterial infection
      • Opportunistic infection
      • Malignancy (Kaposi sarcoma, lymphoma)
      • "Capillary leak" syndrome, which is associated with effusions in other body cavities
    • Viral: The most common cause of infectious pericarditis and myocarditis is viral. Common etiologic organisms include coxsackievirus A and B, and hepatitis viruses.
    • Pyogenic (pneumococci, streptococci, staphylococci, Neisseria, Legionella species)
    • Tuberculous
    • Fungal (histoplasmosis, coccidioidomycosis, Candida)
    • Other infections (syphilitic, protozoal, parasitic)
  • Neoplasia
    • Neoplastic disease can involve the pericardium through the following mechanisms:
      • Direct extension from mediastinal structures or the cardiac chamber
      • Retrograde extension from the lymphatic system
      • Hematologic seeding
      • As mentioned previously, the most common cases of malignant effusion are lung, breast, lymphoma, and leukemia. However, patients with malignant melanoma or mesothelioma have a high prevalence of associated pericardial effusions.
  • Postoperative/postprocedural
    • Pericardial effusions are common after cardiac surgery. In 122 consecutive patients studied serially before and after cardiac surgery, effusions were present in 103 patients; most appeared by postoperative day 2, reached their maximum size by postoperative day 10, and usually resolved without sequelae within the first postoperative month. In a retrospective survey of more than 4,500 postoperative patients, only 48 were found to have moderate or large effusions by echocardiography; of those, 36 met diagnostic criteria for tamponade.[5]
    • Use of preoperative anticoagulants, valve surgery, and female sex were all associated with a higher prevalence of tamponade. Symptoms and physical findings of significant postoperative pericardial effusions are frequently nonspecific, and echocardiographic detection and echo-guided pericardiocentesis, when necessary, are safe and effective; prolonged catheter drainage reduces the recurrence rate.[6]
    • Pericardial effusions in cardiac transplant patients are associated with an increased prevalence of acute rejection.[7]
  • Other less common causes include the following:
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Contributor Information and Disclosures
Author

William J Strimel, DO  Fellow, Cardiovascular Disease, Scott and White Memorial Hospital

William J Strimel, DO, is a member of the following medical societies: American College of Cardiology, American College of Physicians, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Coauthor(s)

Ramin Assadi, MD  Senior Fellow, Department of Cardiology, Loma Linda University School of Medicine

Ramin Assadi, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Ali A Sovari, MD, FACP  Clinical and Research Fellow in Cardiovascular Medicine, Section of Cardiology, University of Illinois College of Medicine; Staff Physician and Hospitalist, St John Regional Medical Center, Cogent Healthcare, Inc

Ali A Sovari, MD, FACP is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Physiological Society, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Abraham G Kocheril, MD, FACC, FACP, FHRS  Professor of Medicine, University of Illinois College of Medicine

Abraham G Kocheril, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, Cardiac Electrophysiology Society, Central Society for Clinical Research, Heart Failure Society of America, and Illinois State Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Justin D Pearlman, MD, PhD, ME, MA  Director of Advanced Cardiovascular Imaging, Professor of Medicine, Professor of Radiology, Adjunct Professor, Thayer Bioengineering and Computer Science, Dartmouth-Hitchcock Medical Center

Justin D Pearlman, MD, PhD, ME, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ronald J Oudiz, MD, FACP, FACC, FCCP  Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, and American Thoracic Society

Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Encysive Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria; Lilly Grant/research funds Clinical Trials + honoraria; LungRx Clinical Trials + honoraria; Bayer Grant/research funds Consulting

Amer Suleman, MD  Private Practice

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Joseph L Fredi, MD  Assistant Professor of Medicine, Director of Acute MI Program, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center

Joseph L Fredi, MD is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Susan Noe, MD to the development and writing of this article.

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Image is from a patient with malignant pericardial effusion. Note the "water-bottle" appearance of the cardiac silhouette in the anteroposterior (AP) chest film.
Echocardiogram (parasternal, long axis) of a patient with a moderate pericardial effusion.
This image is from a patient with malignant pericardial effusion. The effusion is seen as an echo-free region to the right of the left ventricle (LV).
This electrocardiogram (ECG) is from a patient with malignant pericardial effusion. The ECG shows diffuse low voltage, with a suggestion of electrical alternans in the precordial leads.
Subcostal view of an echocardiogram that shows a moderate-to-large amount of pericardial effusion.
This echocardiogram shows a large amount of pericardial effusion (identified by the white arrows).
 
 
 
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