4. Pericardial Effusion

📄 Definition

Pericardial effusion refers to the accumulation of fluid in the pericardial sac. It can be small and asymptomatic or large and haemodynamically significant, potentially leading to cardiac tamponade.

⚠️ Causes – 

Mnemonic: PERICARDIAL

  • Pericarditis (viral, bacterial, TB)

  • Endocrine (hypothyroidism)

  • Rheumatological (SLE, RA)

  • Iatrogenic (post-cardiac surgery, post-MI – Dressler’s)

  • Cancer (lung, breast, lymphoma, metastases)

  • Autoimmune (e.g. vasculitis)

  • Renal failure (uraemia)

  • Drug-induced (hydralazine, isoniazid)

  • Infection (especially TB in high-risk populations)

  • AIDS / HIV

  • Leukaemia/lymphoma (haematological malignancy)

📋 Clinical Features

  • Chest pain (pleuritic, improved by sitting forward)

  • Dyspnoea

  • Muffled heart sounds

  • Raised JVP (if tamponade)

  • Pulsus paradoxus (drop in SBP >10 mmHg on inspiration)

  • Distant heart sounds

🔬 Investigations

🥇 First-Line

  • ECG: Low-voltage QRS ± electrical alternans

  • CXR: Enlarged “water bottle” cardiac silhouette if large

  • Bloods: FBC, U&Es, CRP/ESR, troponin, TFTs, autoimmune screen

  • Echo: Diagnostic – shows size and haemodynamic impact of effusion

🥈 Second-Line

  • CT/MRI Heart: If unclear cause or planning pericardial window

  • Pericardiocentesis: Diagnostic if infective or malignant cause suspected

Management – Mnemonic: DRAIN FLUID

  • Determine cause (infective, malignant, inflammatory)

  • Refer cardiology for large/rapid effusions

  • Anti-inflammatories (NSAIDs ± colchicine if pericarditis-related)

  • Initiate antibiotics if infection suspected

  • NSAIDs + colchicine (if inflammatory origin)

  • Follow-up echo

  • Limit activity until resolution

  • Urgent pericardiocentesis if tamponade

  • Investigate underlying malignancy or autoimmune

  • Dialysis if uraemic

⚠️ Complications

  • Cardiac tamponade

  • Constrictive pericarditis (chronic scarring)

  • Recurrent pericardial effusions

  • Infective progression (purulent pericarditis)

🔺 Last updated in line with ESC 2023 Guidelines on Pericardial Diseases and NICE CKS

Published: April 2023 • Last updated: June 2023
Last reviewed: August 2025
✅ PASSMAP ensures all content is NICE-aligned and reviewed for Physician Associate Registration Assessment (PARA) success.

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