2. INTRODUCTION Presence of abnormal amount and/or character of fluid in the pericardial space Can be caused by LOCAL/SYSTEMIC/IDIOPATHIC causes Can be ACUTE or CHRONIC (symptoms) Important implications for prognosis (intrathoracic neoplasm), diagnosis (myopercarditis) or both (dissecting of ascentding aorta) Treatment directed at removal of pericardial fluid and alleviation of the underlying cause

3. PHYSIOLOGY Volume of fluid: 15-50 ml. Essentially and ultrafiltrate of plasma Total protein generally low. Albumin conc. HIGH. Contribution of pericardial fluid: end-diastolic pressure (mostly RA,RV) ensure uniform contraction of the myocardium Acute (80ml) vs. Chronic (up to 2lt).

4. ETIOLOGY As a component of any pericardial disorder or 2ry to a systemic disorder: Acute idiopathic or viral pericaditis Infectious: Viral, Purulent pericarditis, Tuberculous, HIV Post MI/post cardiac surgery Malignancy (lung, breast, hodgkin’s, mesothelioma) Mediastinal radiation Autoimmune disease Dialysis, Ch. Renal failure Hypothyroidism (myxedema), ovarian hyperstimulation synd. Drugs: procainamide, isoniazid, hydralazine, anticoagulants.

5. ETIOLOGY HEMORRHAGIC PERICARDIAL EFFUSION: Malignancy (26%) Trans-catheter interventions and/or pacemaker insertion (18%) Post-pericardiotomy syndrome (13%) Complication of MI (free wall rupture, thrombolysis) (11%) Idiopathic (10%) Uremic (7%) Aortic dissection (4%) Trauma (3%) Other (8%)

6. CLINICAL- SYMPTOMS CVS: chest pain, pericardial pain (relieved by sitting), light headedness, syncope, palpitations RESP: cough, dyspnea, hoarsness GI: hiccoughs NEUR: anxiety, confusion

7. CLINICAL- SIGNS CVS: BECK’s triad of tamponade (hypotension, muffled heart sounds, jugular venous distension), pulsus paradoxus, pericardial friction rub, tachycardia, hepatojugular reflux. RESP: tachypnea, decreased breath sounds, Ewart sign GI: hepato-splenomegaly EXTREMITIES: weakened peripheral pulses, edema, cyanosis.

8. DIAGNOSIS Suspect when: All cases of acute pericarditis Unexplained persistent fever +\- source. Purulent per. New radiographic cardiomegaly without pul. Congestion. Isolated left pleural effusion Hemodynamic deterioration after MI, cardiac surgery, invasive cardiac procedures.

9. APPRAOCH Clinically, ECG, X-RAY. Once pericardial effusion is suspected: Establish the presence of effusion : clinically ECG, ECHO (sensitive, specific, hemodynamic significance Assess the hemodynamic impact Establish the cause

10. Establish the presence of effusion According to ACC/AHA/ASE 2003 Clinically – insensitive and nonspecific. ECG- low voltage QRS complexes <5mm in all limb leads, <10mm in V1-V6. (tamponade and inflammation); alternans in P and QRS complexes- pathognomonic. ECHO: sensitive, specific, hemodynamic significance CT, MRI

11. Assess hemodynamic impact Ranges from no significance  mild compromise  cardiac tamponade Factors determining the degree of hemodynamic compromise: 1. Volume 2. Rate of accumulation (acute vs. subacute) 3. Pericardium is scarred or adherent

12. Establish the cause of effusion Often recognized by the clinical setting in which it occurs (cancer, MI, hypothyroidism, renal failure) Chance of diagnosis rises as the effusion is larger. (15/20% vs. 90%; why? Diag., aggressive approach) Clinical assess.: size; +/- tamponade; inflammatory signs (chest pain, pericardial friction rub, fever diffused ST elev.) Lab. Tests: CBC, chemistry+renal function, thyroid, anti dsDNA,complement, chst CT Pericardiocentesis & biopsy : culture, cytology, PCR. protein,LDH,Glucose,RBC,WBC: do not distinguish exudate from transudate

13. TREATMENT CONSIDER: underlying disease, hemodynamic significance, presence of tamponade. Underlying disease: infectious, malignant, uremic peric. MI, collagen vascular disease. Cardiac tamponade: volume resuscitation (RA pressure 10-12mmHg). Pericardial fluid drainage: percutaneous/ pericadiectomy.

14. Summery Abnormal amount/character of pericardial fluid LOCAL/SYSTEMIC/IDIOPATHIC causes ACUTE vs. CHRONIC Clinical – not specific. Tamponade. APPROACH: Clinically, ECG, X-RAY; Establish the presence of effusion ; Assess the hemodynamic impact Establish the cause TREATMENT: underlying disease, hemodynamic significance, presence of tamponade.