Pericardial effusion

Disease Description (Causes and Symptoms)

• Definition summary: A condition in which fluid abnormally accumulates between the two layers of the pericardium (the membrane surrounding the heart).
• Pathophysiology: When fluid accumulation compresses the heart, intrapericardial pressure rises and cardiac expansion and filling are restricted, which may cause hemodynamic abnormalities (cardiac tamponade). Rapid accumulation can cause symptoms even with a small amount of fluid, whereas gradual accumulation may be asymptomatic despite a relatively large amount.
• Major causes: Viral (idiopathic) inflammation, tuberculosis, malignancy (metastatic cancer), hypothyroidism (myxedema), systemic lupus erythematosus (SLE), rheumatoid arthritis, chronic renal failure (uremic), radiation therapy and chemotherapy, fungal infection, trauma, complications after myocardial infarction, and others.
• Representative symptoms: Small effusions are asymptomatic (found incidentally). With a large effusion or rapid increase, symptoms may include dyspnea, cough, hoarseness (laryngeal nerve compression), early satiety and loss of appetite, tachycardia, jugular venous distention (JVD), hepatomegaly and peripheral edema, and muffled heart sounds on auscultation. In cardiac tamponade, hypotension, weakness, sympathetic overactivity, and pulsus paradoxus (a decrease in systolic blood pressure of 10 mmHg or more during inspiration) may occur.

Treatment Methods

• General principles: Treatment of the underlying disease (antituberculous drugs, chemotherapy, thyroid hormone replacement, anti-inflammatory treatment, etc.) plus management according to symptoms and hemodynamic status. Small, asymptomatic effusions can often be managed with observation (periodic echocardiography).
• Medication: For inflammatory causes, NSAIDs (e.g., ibuprofen) and colchicine (used to prevent and reduce recurrence) may be used. Steroids are used for certain autoimmune or steroid-responsive diseases (with caution rather than routinely in emergencies).
• Procedures/Surgery:
  • Pericardiocentesis (percutaneous pericardiocentesis): Emergency drainage and diagnostic evaluation when symptoms occur or hemodynamic abnormalities (tamponade) are present. The drained fluid is tested with cultures, cytology, biochemical tests, and others (in cases of malignant effusion, cancer cells can be diagnosed in approximately 80% of cases). An indwelling catheter (for continued drainage) may be inserted if necessary.
  • Pericardial window or partial pericardiectomy: Intended to prevent recurrence and provide continuous drainage in recurrent, localized, or malignant effusions.
  • Oncologic or infectious-disease treatment in combination with systemic therapy.
• Post-procedure management: Monitoring residual fluid and ischemia with ultrasound, infection management, and blood tests, immune tests, TB testing, tumor markers, pericardial fluid cytology, and others to determine the cause.
• Lifestyle management and precautions: Visit the emergency department if symptoms acutely worsen (severe dyspnea, fainting, or hypotension). Strenuous exercise and intense physical activity should be restricted according to symptoms and clinical course. Whether to take anticoagulants requires individual assessment, considering the risk of bleeding and the underlying cause.

Outpatient Visit Checklist (Including Preparations, Records, and Example Questions)

• Items/materials to prepare or bring:
  • A list of all medications currently being taken (prescription drugs, OTC drugs, and supplements)
  • Copies or photos of previous test results (echocardiography reports, chest X-rays, ECG, and blood test results)
  • Past medical history (tuberculosis, cancer, autoimmune disease, renal failure, radiation therapy, etc.) and surgical history
• Symptom records:
  • Onset and worsening pattern of dyspnea (during exercise vs. at rest), and changes with position (whether it worsens when lying down)
  • Chest pain (characteristics and duration), cough, fever, weight changes, and loss of appetite
  • Any recent trauma, cancer diagnosis and progression, and whether dialysis is being received
• Objective items the doctor may ask about during the outpatient visit: blood pressure, heart rate, respiratory rate, oxygen saturation, presence of jugular venous distention, hepatomegaly, edema, and others
• Test preparation: No special fasting is required. If necessary, guidance will be provided for scheduling echocardiography, chest X-ray, ECG, and blood tests (for infection, inflammation, thyroid function, renal function, etc.).

Examples of General Questions to Ask the Doctor

• "What is the current amount of fluid in my pericardium, and how quickly is it increasing? Do I need a procedure right away?"
• "What are the advantages, disadvantages, and side effects of the recommended treatment options (medication, drainage, or surgery)?"
• "What is the risk of recurrence, and how will follow-up testing be performed (interval and method)?"
• "What should I be careful about in my lifestyle (exercise, work, and travel)?"

Examples of Disease-Specific Questions

• "Based on my current symptoms, am I at risk of cardiac tamponade? What symptoms should prompt me to go to the emergency department immediately?"
• "What is the likelihood that cancer cells will be found in the pericardial fluid test, and when are additional tests (such as a pericardial biopsy) needed if the result is negative?"