Pericardial Effusion Treatment & Management

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

Medical Care

Initially, medical care of pericardial effusion is focused on determination of the underlying etiology.

  • Aspirin/nonsteroidal anti-inflammatory agents (NSAIDs)
    • Most acute idiopathic or viral pericarditis occurrences are self-limited and respond to treatment with aspirin (650 mg q6h) or another NSAID.
    • Aspirin may be the preferred nonsteroidal agent to treat pericarditis after myocardial infarction because other NSAIDs may interfere with myocardial healing.
    • Indomethacin should be avoided in patients who may have coronary artery disease.
    • Meurin et al performed a multicenter, randomized, double-blind trial on the effect of the NSAID diclofenac in reducing postoperative pericardial effusion volume. Diclofenac, 50 mg, or placebo twice daily for 14 days was given to 196 patients at high risk for tamponade because of pericardial effusion more than 7 days after cardiac surgery. The authors found that diclofenac was not effective at reducing the size of the effusion or preventing late cardiac tamponade.[15]
  • Colchicine: The routine use of colchicine is supported by results from the COlchicine for acute PEricarditis (COPE) trial. In this trial, 120 patients with a first episode of acute pericarditis (idiopathic, acute, postpericardiotomy syndrome, and connective tissue disease) entered a randomized, open-label trial comparing aspirin treatment alone with aspirin plus colchicine (1-2 mg for the first day followed by 0.5-1 mg/d for 3 mo). Colchicine reduced symptoms at 72 hours (11.7% vs 36.7%; P =0.03) and reduced recurrence at 18 months (10.7% vs 36.7%; P =0.004; 5 needed treatment). Colchicine was discontinued in 5 patients because of diarrhea. No other adverse events were noted. Importantly, none of the 120 patients developed cardiac tamponade or progressed to pericardial constriction.[16]
  • Steroids
    • Steroid administration early in the course of acute pericarditis appears to be associated with an increased incidence of relapse after tapering the steroids.
    • In the COPE trial, steroid use was an independent risk factor for recurrence (odds ratio=4.3). Also, an observational study strongly suggests that the use of steroids increases the probability of relapse in patients treated with colchicine.[16]
    • Systemic steroids should be considered only in patients with recurrent pericarditis unresponsive to NSAIDs and colchicine or as needed for treatment of an underlying inflammatory disease. If steroids are to be used, an effective dose (1-1.5 mg/kg of prednisone) should be given, and it should be continued for at least 1 month before slow tapering.
    • The intrapericardial administration of steroids has been reported to be effective in acute pericarditis without producing the frequent reoccurrence of pericarditis that complicates the use of systemic steroids, but the invasive nature of this procedure limits its use.
  • Hemodynamic support
    • Patients who have effusions with actual or threatened tamponade should be considered to have a true or potential emergency. Most patients require pericardiocentesis to treat or prevent tamponade. However, treatment should be carefully individualized.
    • Hemodynamic monitoring with a balloon flotation pulmonary artery catheter is useful, especially in those with threatened or mild tamponade in whom a decision is made to defer pericardiocentesis. Hemodynamic monitoring is also helpful after pericardiocentesis to assess both reaccumulation and the presence of underlying constrictive disease. However, insertion of a pulmonary artery catheter should not be allowed to delay definitive therapy in critically ill patients.
    • Intravenous fluid resuscitation may be helpful in cases of hemodynamic compromise.
    • In patients with tamponade who are critically ill, intravenous positive inotropes (dobutamine, dopamine) can be used but are of limited use and should not be allowed to substitute for or delay pericardiocentesis.
  • Antibiotics
    • In patients with purulent pericarditis, urgent pericardial drainage combined with intravenous antibacterial therapy (eg, vancomycin 1 g bid, ceftriaxone 1-2 g bid, and ciprofloxacin 400 mg/d) is mandatory. Irrigation with urokinase or streptokinase, using large catheters, may liquify the purulent exudate, but open surgical drainage is preferable.
    • The initial treatment of tuberculous pericarditis should include isoniazid 300 mg/day, rifampin 600 mg/day, pyrazinamide 15-30 mg/kg/day, and ethambutol 15-25 mg/kg/day. Prednisone 1-2 mg/kg/day is given for 5-7 days and progressively reduced to discontinuation in 6-8 weeks. Drug sensitivity testing is essential. Uncertainty remains whether adjunctive corticosteroids are effective in reducing mortality or progression to constriction. Surgical resection of the pericardium remains the appropriate treatment for constrictive pericarditis. The timing of surgical intervention is controversial, but many experts recommend a trial of medical therapy for noncalcific pericardial constriction and pericardiectomy in nonresponders after 4-8 weeks of antituberculosis chemotherapy.
  • Antineoplastic therapy (eg, systemic chemotherapy, radiation) in conjunction with pericardiocentesis has been shown to be effective in reducing recurrences of malignant effusions.
  • Corticosteroids and NSAIDs are helpful in patients with autoimmune conditions.
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Surgical Care

Surgical care of pericardial effusion includes the following:

  • Subxiphoid pericardial window with pericardiostomy[17]
    • This procedure is associated with low morbidity, mortality, and recurrence rates, and can be considered as a reasonable alternative diagnostic or treatment modality to pericardiocentesis in selected patients.
    • It can be performed under local anesthesia. This is advantageous because general anesthesia often leads to decreased sympathetic tone, resulting in hemodynamic collapse in patients with pericardial tamponade and shock.
    • It may be less effective when effusion is loculated.
    • One study indicated it may be safer and more effective at reducing recurrence rates than pericardiocentesis. However, only patients who were hemodynamically unstable underwent pericardiocentesis, and no change in overall survival rate was observed.
  • Thoracotomy
    • This should be reserved for patients in whom conservative approaches have failed.
    • Thoracotomy allows for creation of a pleuropericardial window, which provides greater visualization of pericardium.
    • Thoracotomy requires general anesthesia and thus has higher morbidity and mortality rates than the subxiphoid approach.
  • Video-assisted thoracic surgery[18]
    • Video-assisted thoracic surgery (VATS) enables resection of a wider area of pericardium than the subxiphoid approach without the morbidity of thoracotomy.
    • The surgeon is able to create a pleuropericardial window and address concomitant pleural pathology, which is especially common in patients with malignant effusions.
    • One disadvantage of VATS is that it requires general anesthesia with single lung ventilation, which may be difficult in otherwise seriously ill patients.
  • Median sternotomy
    • This procedure is reserved for patients with constrictive pericarditis.
    • Operative mortality rate is high (5-15%).
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Consultations

  • A cardiologist should be involved in the care of patients with pericardial effusion.
  • Cardiothoracic surgery may be required for recurrent or complicated cases (see Surgical Care).
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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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