**2.4 Treatment**

*Inflammatory Heart Diseases*

ECG [2, 3, 11].

usually associated with sinus tachycardia.

assess the hemodynamic impact; and (3) effort to identify the underlying etiology. Transthoracic echocardiography (TTE) is recommended in all patients with suspected effusion as a class I, level C recommendation. Further imaging modalities such as computed tomography (CT) scan, cardiac magnetic resonance imaging (CMRI), pericardial fluid analysis, or biopsy can be considered in cases where loculated effusion, masses, or thickening of the pericardium are suspected. Basic diagnostic work up, including blood counts, chemistry, thyroid function tests, cardiac biomarkers, inflammatory markers such as C-reactive protein (CRP) and sedimentation rate (ESR), electrocardiogram (ECG), and chest X-ray, should be done [2, 10]. ECG findings in pericardial effusion include low QRS voltage and electrical alternans, a finding of large pericardial effusion or tamponade that is

TTE is recommended as the first modality to determine the hemodynamic significance of pericardial effusion and is highly sensitive and specific. The pericardial fluid appears as echo-lucent space between the pericardium and epicardium on TTE. The semi-quantitative assessment for largest echo-free space in echocardiographic views provides an assessment of severity. Mild pericardial effusion is considered <10 mm, moderate between 10 and 20 mm, and large effusion is any collection >20 mm. The collection of effusion follows gravity initially in the inferolateral position close to right atrium in the apical four chamber view with the patient in a supine-left lateral position. The pattern of collection changes to circumferential in the pericardium with increasing amount of fluid (**Figure 1**). After the development of a large amount of effusion, the heart can be seen swinging in the pericardial cavity, a finding that correlates with electrical alternans on

Cardiac CT and CMRI are useful imaging modalities for the evaluation of pericardial effusion and tamponade especially for more detailed assessment and the localization of the effusion and associated abnormalities in the mediastinum, lungs,

**14**

**Figure 1.**

*Large circumferential pericardial effusion.*

For small-to-medium sized, asymptomatic pericardial effusion without signs of hemodynamic instability, regular outpatient follow-up with clinical examination and/or echocardiography should be preferred. Management of pericardial effusion with signs of inflammation (pericarditis) should follow the standard or treatment for pericarditis; however, in the absence of any inflammation, antiinflammatory drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids, are generally not effective. Such cases as well as cases with large effusion that failed empiric anti-inflammatory therapy would require pericardiocentesis. Recurrence of effusion is fairly common and further management options include pericardial window formation or pericardiectomy. A study comparing patients age 15–65 to a group of patients age 66–88 years showed elderly people had more persistence of effusion (6.3 vs. 14%; P < 0.05) but no statistically significant difference in mortality (24 vs. 30%) or evolution of cardiac constriction (4 vs. 2%) during median follow up time of 11 months [6]. There is no standard guideline available for elderly patients regarding pleural effusions; however, the expert consensus suggests adjusting the type and dosages of medications with special attention to drug interactions and renal function given the prevalence of polypharmacy and renal dysfunction in the geriatric population [2]. A proposed management algorithm for pericardial effusion of unknown origin is depicted in **Figure 2** [2, 3].
