Pericardial Effusion - Diagnostic Tests and Procedures

5/15/02 (Lassiter)

Question: Which diagnostic tools are most appropriate in diagnosing pericardial effusion?

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Unique Identifier:9149572

Authors: Meyers DG. Meyers RE. Prendergast TW.

Institution: Department of Internal Medicine, Kansas University Medical Center, Kansas City, USA.

Title: The usefulness of diagnostic tests on pericardial fluid. [see comments.].

Source: Chest. 111(5):1213-21, 1997 May.

Abstract: STUDY OBJECTIVES: To determine the physical, chemical, and cellular characteristics of pericardial fluid in various disease states and to assess their diagnostic accuracies. SETTING: A metropolitan university hospital. DESIGN: Consecutive case series. PATIENTS: One hundred seventy-five hospital patients, aged 1 month to 87 years, who had undergone pericardiocentesis (n = 165) or control subjects who had undergone open heart surgery (n = 10) between 1984 and 1996. MEASUREMENTS: The appearance of pericardial fluid and results of chemistry tests, cell counts, cytologic studies, Gram's stain, and microbial cultures were obtained by chart review. The etiology of each pericardial fluid sample was determined using prospective diagnostic criteria. RESULTS: Exudates differed from transudates by higher leukocyte counts and ratios of fluid to serum lactate dehydrogenase levels. Fluid glucose levels were significantly less in exudates. Sensitivity for detecting exudates was high for specific gravity > 1.015 (90%), fluid total protein > 3.0 g/dL (97%), fluid to serum protein ratio > 0.5 (96%), fluid lactate dehydrogenase ratio > 0.6 (94%), and fluid to serum glucose ratio < 1.0 (85%). None of these indicators were specific. Fluid total protein and specific gravity were moderately correlated (r = 0.56). Fluid cytologic study had a sensitivity of 92% and specificity of 100% for malignant effusion. No other test was diagnostic for a specific etiology. Among infection-associated effusions, culture-positive fluid had more neutrophils, higher lactate dehydrogenase levels, and lower ratios of fluid to serum glucose than culture-negative (parainfective) fluid. CONCLUSIONS: Evaluation of pericardial fluid might be limited to cell count, glucose, protein, and lactate dehydrogenase determinations plus bacterial culture and cytology. While not used routinely, other tests that may be highly specific for particular diseases should be ordered only to confirm a high clinical suspicion. CAS Registry/EC Number 0 (Blood Glucose). 0 (Blood Proteins). 0 (Dyes). 0 (Proteins). 50-99-7 (Glucose). EC 1-1-1-27 (Lactate Dehydrogenase).

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Unique Identifier:8955601

Authors: Malamou-Mitsi VD. Zioga AP. Agnantis NJ.

Institution: Department of Pathology, Medical School, University of Ioannina, Greece.

Title: Diagnostic accuracy of pericardial fluid cytology: an analysis of 53 specimens from 44 consecutive patients.

Source: Diagnostic Cytopathology. 15(3):197-204, 1996 Sep.

Abstract: Over a 7-yr period, a total of 53 pericardial fluid specimens from 44 patients was examined. A correlation between cytological and histological diagnosis was made in 19 of these cases. In the remaining 25 cases, where a biopsy was not performed, the cytological diagnosis was correlated with the final clinical diagnosis and the patients' clinical outcome. Finally, in 9 out of 14 cases of malignancy where both cytological and a histological diagnosis was made, the cytologic prediction of the histologic type of cancer was evaluated. The overall sensitivity was 100%, the overall specificity was 93.3%, and the overall cytological accuracy was 95.4%. The predictive value of the correct histologic type of cancer by cytology was 77.7%. Our findings show that the careful cytomorphological examination of pericardial fluid aspirates is a valuable, reliable, and diagnostically highly accurate method, which could be performed on a routine basis in a busy cytopathology department. Judiciously chosen ancillary procedures, as well as clinicopathological correlation, are of great value for an accurate diagnosis in problematic cases.

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Unique Identifier:10532206

Authors: Dogan R. Demircin M. Sarigul A. Ciliv G. Bozer AY.

Institution: Department of Thoracic and Cardiovascular Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey.

Title: Diagnostic value of adenosine deaminase activity in pericardial fluids.

Source: Journal of Cardiovascular Surgery. 40(4):501-4, 1999 Aug.

Abstract: BACKGROUND: The activity of adenosine deaminase (ADA) was determined in serum and pericardial fluid of 70 patients (ages 21 to 71 years) with pericardial effusions of various etiologies and in 15 control subjects. METHODS: The patients were subdivided into five groups on the basis of definite diagnosis: 1) 24 patients with tuberculosis; 2) 22 with malignancies; 3) 12 with uremic pericarditis; 4) 12 with purulent pericarditis; 5) 15 control individuals without pericardial disease. The activity of ADA was determined at the same time in serum and cell-free pericardial fluid according to the method of Karker with minor modification. RESULTS: Mean (+/-SD) ADA activity in pericardial fluid was 66.92+/-4.12 IU/L in group 1; 27.50+/-6.02 in group 2; 28.65+/-4.73 in group 3; 53.05+/-11.14 in group 4; and 5.67+/-1.99 in group 5. Comparing the level achieved in group 1 with all others, the difference is significant at the p<0.001 level. When the cut-off value of 50 IU/L is used the sensitivity of the test for diagnosis of tuberculous effusion is 1, and the specificity is 0.83. Statistical analysis showed that there was no correlation between serum ADA activity and ADA activity in pericardial fluid. CONCLUSIONS: We recommend that determinations of ADA activity in pathologic pericardial fluids seem to be of great value in the early diagnosis of tuberculous pericardial effusions. Levels above 50 IU/L in effusions indicate probable tuberculosis. CAS Registry/EC Number EC 3-5-4-4 (Adenosine Deaminase).

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Unique Identifier:10502224

Authors: Merce J. Sagrista-Sauleda J. Permanyer-Miralda G. Evangelista A. Soler-Soler J.

Institution: Servei de Cardiologia, Hospital General Universitari Vall d'Hebron, Spain.

Title: Correlation between clinical and Doppler echocardiographic findings in patients with moderate and large pericardial effusion: implications for the diagnosis of cardiac tamponade.

Source: American Heart Journal. 138(4 Pt 1):759-64, 1999 Oct.

Abstract: BACKGROUND: Clinical data are of unquestionable value for management purposes in cardiac tamponade, whereas the precise value of Doppler echocardiographic findings is not yet fully understood. We aimed to prospectively assess the correlation between clinical and Doppler echocardiographic signs in the diagnosis of cardiac tamponade in a large series of patients with pericardial effusion. METHODS: During a 2-year period, all patients with moderate and large pericardial effusion were prospectively assessed. The presence of clinical findings suggesting cardiac tamponade, right cardiac chamber collapse on the echocardiogram, and Doppler venous flow pattern were simultaneously evaluated. RESULTS: One hundred ten patients were included (49 with moderate and 61 with large effusions). Thirty-eight patients showed clinical features suggestive of cardiac tamponade and 72 did not. In patients with clinical tamponade, 90% had collapse of one or more right cardiac chambers, but 4 (10%) did not have any collapse. Venous flow was analyzable in 63%, suggesting tamponade in 75% of the patients. In patients without clinical tamponade, 34% showed collapse of one or more cardiac chambers. Venous flow pattern was normal in 80%, inconclusive in 11%, and only suggestive of tamponade in 9% of patients. If clinical features of tamponade were considered the diagnostic standard, sensitivity and specificity would be 90% and 65% for the presence of any collapse, 68% and 66% for right atrial collapse, 60% and 90% for right ventricular collapse, and 45% and 92% for simultaneous collapse of both chambers. Sensitivity and specificity of venous flow analysis would be 75% and 91%, respectively. CONCLUSIONS: There is a good correlation between absence of collapse and absence of tamponade, but the correlation is poor between collapse and tamponade. Abnormal venous flow has a good correlation with clinical features of tamponade, with a higher sensitivity than right ventricular collapse and a much higher specificity than right atrial collapse.

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Unique Identifier:10432549

Authors: Rozenshtein A. Boxt LM.

Institution: Department of Radiology, St. Luke's/Roosevelt Hospital Center, New York, NY 10003, USA.

Title: Plain-film diagnosis of pericardial disease. [Review] [67 refs]

Source: Seminars in Roentgenology. 34(3):195-204, 1999 Jul.

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Unique Identifier:9619321

Authors: Herzog E. Krasnow N. DePuey G.

Institution: Department of Medicine, St. Luke's/Roosevelt Hospital Medical Center, New York, NY 10025, USA.

Title: Diagnosis of pericardial effusion and its effects on ventricular function using gated Tc-99m sestamibi perfusion SPECT.

Source: Clinical Nuclear Medicine. 23(6):361-4, 1998 Jun.

Abstract: Pericardial effusion is a common disorder associated with a variety of medical disorders. Diagnostic methods of choice include echocardiography, CT, and MRI. However, diagnosing pericardial effusion with radionuclides is uncommon. A pericardial effusion under pressure may result in tamponade and hemodynamic compromise, which constitutes a cardiac emergency, necessitating emergency intervention with pericardiocentesis or pericardiotomy. Presented is an unusual case of a patient who was referred to the nuclear cardiology laboratory for evaluation of atypical chest pain using stress and rest Tc-99m sestamibi perfusion SPECT. The patient had a large pericardial effusion evident on planar projection images and tomograms. From the gated perfusion study, the authors were able to evaluate left and right ventricular function and to exclude cardiac tamponade because there was no evidence of diastolic collapse of the right ventricle. CAS Registry/EC Number 0 (Radiopharmaceuticals). 109581-73-9 (Technetium Tc 99m Sestamibi).

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Unique Identifier:9490993

Authors: Marinella MA.

Institution: Wright State University School of Medicine, Dayton, Ohio, USA.

Title: Electrocardiographic manifestations and differential diagnosis of acute pericarditis. [Review] [15 refs]

Source: American Family Physician. 57(4):699-704, 1998 Feb 15.

Abstract: Acute pericarditis has many potential etiologies and typically presents as a sharp central chest pain that worsens with recumbency and is relieved by leaning forward. The pathognomonic physical finding of acute pericarditis is the pericardial friction rub, which is usually auscultated along the lower left sternal border. The electrocardiogram (ECG) is a useful, simple tool that may aid in the diagnosis of acute pericarditis. Typical ECG findings include diffuse concave-upward ST-segment elevation and, occasionally, PR-segment depression. ECG changes of both acute myocardial infarction and early repolarization can appear similar to ECG changes of acute pericarditis. However, these conditions can usually be excluded by an accurate history, physical examination and recognition of a few key features on the ECG. [References: 15]

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Unique Identifier:8697827

Authors: Eisenberg MJ. de Romeral LM. Heidenreich PA. Schiller NB. Evans GT Jr.

Institution: Department of Medicine, University of California, San Francisco 94143, USA.

Title: The diagnosis of pericardial effusion and cardiac tamponade by 12-lead ECG. A technology assessment. [see comments.].

Source: Chest. 110(2):318-24, 1996 Aug.

Abstract: OBJECTIVE: This study was designed to determine the diagnostic value of 12-lead ECG for pericardial effusion and cardiac tamponade. DESIGN: Cross-sectional study. SETTING: University hospital. PATIENTS: Hospitalized patients with and without pericardial effusion and cardiac tamponade. MEASUREMENTS AND RESULTS: In a blinded manner, we reviewed 12-lead ECGs from 136 patients with echocardiographically diagnosed pericardial effusions (12 of whom had cardiac tamponade) and from 19 control subjects without effusions. We examined the diagnostic value of three ECG signs: low voltage, PR segment depression, and electrical alternans. We found that all three ECG signs were specific but not sensitive for pericardial effusion (specificity, 89 to 100%; sensitivity, 1 to 17%) and cardiac tamponade (specificity, 86 to 99%; sensitivity, 0 to 42%). None of the ECG signs were associated with pericardial effusions of all sizes, but low voltage was associated with large and moderate pericardial effusions (odds ratio = 2.5; 95% confidence interval [CI] = 0.9 to 6.5; p = 0.06) and with cardiac tamponade (odds ratio = 4.7; 95% CI = 1.1 to 21.0; p = 0.004). In contrast, PR segment depression was associated only with cardiac tamponade (odds ratio = 2.0; 95% CI = 1.0 to 4.0; p = 0.05), while electrical alternans was not associated with either pericardial effusion or cardiac tamponade. CONCLUSIONS: Low voltage and PR segment depression are ECG signs that are suggestive, but not diagnostic, of pericardial effusion and cardiac tamponade. Because these ECG findings cannot reliably identify these conditions, we conclude that 12-lead ECG is poorly diagnostic of pericardial effusion and cardiac tamponade.

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Unique Identifier:8840855

Authors: Nugue O. Millaire A. Porte H. de Groote P. Guimier P. Wurtz A. Ducloux G.

Institution: C Division of Cardiology, Heart Hospital, France.

Title: Pericardioscopy in the etiologic diagnosis of pericardial effusion in 141 consecutive patients.

Source: Circulation. 94(7):1635-41, 1996 Oct 1.

Abstract: BACKGROUND: Although previous small series have documented the utility of pericardioscopy for accurate etiologic diagnosis of pericardial effusion, this technique remains underused. The aim of our study was to assess the benefits and risks of surgical pericardioscopy in a large prospective series. METHODS AND RESULTS: One hundred forty-one consecutive patients with unexplained pericardial effusion underwent 142 pericardioscopies with a rigid mediastinoscope. For each patient, the etiologic data obtained by pericardioscopy (visualization of pericardium, guided biopsies, subxiphoid window biopsy, and fluid analysis) were compared with the results that would have been obtained with only conventional surgical drainage and biopsy (subxiphoid window biopsy and fluid analysis). After complete workup, a specific cause was found in 69 cases (48.6%); the other 73 cases were considered idiopathic effusions (51.4%). Procedural and in-hospital mortality was 8 of 141 patients (5.6%). No death was directly attributable to pericardioscopy. During long-term follow-up (median duration, 24 months; range, 6 to 96), a previously unrecognized cause was discovered in 6 patients (4%). By comparing the areas under the receiver-operating characteristic curves, the diagnostic advantage of pericardioscopy was significant for the whole series (pericardioscopy, 0.98 +/- 0.011; conventional surgical drainage, 0.89 +/- 0.029; P < .001). The increase in sensitivity was more marked for some types such as neoplastic (21%), radiation-induced (100%), or purulent (83%) effusions. CONCLUSIONS: Our data demonstrate that pericardioscopy increases the diagnostic sensitivity of surgical pericardial drainage and biopsy without specific risk.