Evaluation of pericardial effusion

Diseases

Summary

Pericardial effusion is present when the fluid in the pericardial space exceeds its physiologic amount (≤50 mL). In the clinical setting, pericardial effusion is relatively common. It may be detected incidentally on a cardiac or chest imaging study, or manifest on the background of a cardiac or systemic disease.

The significance of effusions lies in their relationship to an underlying disease state and in their potential to affect a patient's hemodynamics.

Epidemiology

Data from the Framingham cohort suggest that pericardial effusion may be present in up to 6.5% of the general adult population.[1] Prevalence increased with age, from <1% in patients ages 20 to 30 years to more than 15% in patients ages 80 years and over. Most people in the study had small effusions and no recognizable cardiac disease.[1]

In the clinical setting, the prevalence of pericardial effusion depends on the patient population studied. Over a 6-year period, the mean annual prevalence and incidence of pericardial effusion in an echocardiography laboratory of a large Italian hospital was 3% and 9%, respectively.[2] In high-risk emergency department patients, the prevalence of pericardial effusion has been reported in the range of 13% to 20%.[3] One meta-analysis reported pooled pericardial effusion prevalence of 19.5% across studies that included patients with pulmonary arterial hypertension, chronic heart failure, myocardial infarction, and malignancy.[4]

Pericardial anatomy and physiology

The normal pericardium consists of both fibrous and serous components. The fibrous layer forms a sac that contains the heart and the roots of the great vessels. The serous part is further divided into a layer that is adherent to the heart and epicardial fat (epicardium or visceral pericardium) and a layer that lines the internal surface of the fibrous layer (parietal pericardium). The pericardial space enclosed between the visceral and the parietal pericardium normally contains up to 50 mL of serous fluid. A pericardial effusion is present when accumulated fluid in the pericardial space exceeds this physiologic amount.[5]

The pericardium serves as a protective barrier, promotes efficient cardiac function, and prohibits excessive displacement of the heart.

Under normal conditions, a pericardial reserve volume exists to accommodate physiologic changes in ventricular filling conditions. However, if this reserve volume is exceeded, pericardial pressure increases rapidly and significantly limits cardiac filling. The relatively inelastic pericardium is able to stretch under conditions of chronic stress such as left ventricular dilation or a slowly accumulating pericardial effusion. However, once the pericardial pressure-volume relationship reaches its noncompliant stage, expansion is limited and small increases in volume produce a dramatic increase in pericardial pressure, severely impairing ventricular filling.Image

Classification of pericardial effusion

Pericardial effusion can be classified by:

Onset (acute or subacute vs. chronic [when lasting >3 months])
Distribution (circumferential or loculated)
Hemodynamic impact (cardiac tamponade or no cardiac tamponade)
Composition (serous fluid, blood, rarely air, or gas from bacterial infections)
Size based on a simple semiquantitative echocardiographic assessment.

The size of the effusion on echocardiography indicates the volume of pericardial fluid as follows:[5] [6] [7]

Trivial (seen only in systole)
Small (<10 mm), which corresponds to 50-100 mL pericardial fluid
Moderate (10-20 mm), corresponding to 100-500 mL pericardial fluid
Large (>20 mm), corresponding to >500 mL pericardial fluid
Very large (>25 mm); usually indicates >700 mL pericardial fluid.

The development of a pericardial effusion often has important implications for the diagnosis and/or prognosis of the underlying disease.[5]

Library

Diagram showing the anatomy of the pericardium.
Auscultation of the pericardium: to elicit pericardial rubs the patient is invited to lean forward (A) or rest on elbows and knees (B). Both physical manoeuvres aim to increase the contact of visceral and parietal pericardium.
ECG in acute pericarditis. Nearly ubiquitous ST segment elevation corresponding to ST depression in aVR (lead augmented vector right). Height of ST elevation is about 25% of height of T waves peak in V5-V6. Most PR segments are slightly depressed with respect to the T-P baseline (atrial current of injury).
Parasternal long-axis view of a pericardial effusion (PE); LA = left atrium, LV = left ventricle, RV = right ventricle
Apical 4- chamber view of a 2-dimensional echocardiogram of a patient with tuberculous pericardial effusion; LA = left atrium, LV = left ventricle, Per eff = pericardial effusion; RA = right atrium, RV = right ventricle
CXR in a patient with a pericardial effusion showing typical findings of a water-bottle-shaped cardiac silhouette with a distinct, fat, pericardial fat stripe

Citations

Key Articles

Adler Y, Charron P, Imazio M, et al. 2015 ESC guidelines on the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36:2921-64.[Abstract][Full Text]
Klein AL, Abbara S, Agler DA, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr. 2013 Sep;26(9):965-1012.e15.[Abstract][Full Text]
Isselbacher EM, Preventza O, Black JH 3rd, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on clinical practice guidelines. Circulation. 2022 Nov 2 [Epub ahead of print].[Abstract][Full Text]

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