Pericardial Effusion

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CHAPTER 68 Pericardial Effusion

Lynn S. Broderick

Pericardial effusion can occur from various causes, including infection, trauma, and systemic disease. Infectious causes of pericardial effusion are described in more detail in Chapter 69. This chapter focuses on pericardial effusion secondary to systemic disease.

DEFINITION

Pericardial effusion refers to the abnormal accumulation of fluid within the pericardial space. The pericardial fluid may be a transudate, may be an exudate, or may be hemorrhagic.

PREVALENCE AND EPIDEMIOLOGY

The prevalence of pericardial effusion depends on the underlying cause. Pericardial effusion detectable by echocardiography may be present in 50% of patients with rheumatoid arthritis. Pericardial effusion is also common in patients with systemic lupus erythematosus and scleroderma.

ETIOLOGY AND PATHOPHYSIOLOGY

Pericardial effusion is an abnormal accumulation of fluid within the pericardial space. In the absence of acute inflammation, clinical symptoms depend on the size of the effusion, the rate of accumulation, and the ability of the pericardium to expand. Cardiac tamponade occurs when the intrapericardial pressure is high enough to impede cardiac filling. The pericardial fluid may be a transudate, an exudate, or hemorrhagic. Pericardial effusion is common in some diseases, such as chronic renal disease and heart failure. Pericardial effusion can occur in any collagen vascular disease, but is particularly common in patients with lupus erythematosus and rheumatoid arthritis (Fig. 68-1).

FIGURE 68-1 A 19-year-old man with systemic lupus erythematosus presented with increasingly severe left-sided chest pain, which worsened on inspiration and with movement. CT scan with intravenous contrast medium was performed to evaluate for possible pulmonary embolism. A, Bright blood axial MR image shows a large pericardial effusion (E) and a left pleural effusion (asterisk) causing passive atelectasis of the left lower lobe (L). B-D, Contrast-enhanced axial CT images at the level of the pulmonary artery (P) (B) and at the level of the aortic valve (A) (C), and a coronal reconstructed image (D) show a large pericardial effusion (E). Echocardiography (not shown) showed minimal collapse of the right ventricle during diastole. Pericardiocentesis was performed, and the patient’s symptoms resolved. LV, left ventricle.

Pericardial effusion can occur in patients with acute myocardial infarction, particularly if the infarction is large in size. It can also occur in a delayed manner after myocardial infarction or surgery (Dressler syndrome). Metastatic disease involving the pericardium results in pericardial effusion, often without detectable pericardial nodules or thickening. Pericardial disease is frequent in patients with rheumatoid arthritis, particularly in patients with active disease. Patients are typically asymptomatic, however. Rheumatoid pericardial disease may manifest as serous or serosanguineous fluid. Pericardial fluid can be present in patients with rheumatic fever, although this is an uncommon entity in the United States. In patients with pericardial effusion secondary to rheumatic fever, there is usually a classic presentation of acute pericarditis that occurs 1 week or so after the initial onset of fever.

MANIFESTATIONS OF DISEASE

Clinical Presentation

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