Pericardial effusion and cardiac tamponade symptoms and ecg. This work by ecg guru is licensed under a creative commons attributionnoncommercialsharealike 3. To investigate the association between ecg changes and the presence of pericardial effusion. Inclusion criteria patients who presented with pericardial effusion including cardiac tamponade based on clinical criteria and confirmed by echocardiography were included in the study. Failure to perform a systematic interpretation of the ecg may be detrimental. Supporting findings include inflammatory marker elevation. Echocardiogram or cardiac ultrasound is a noninvasive test that uses sound waves to create images and allows us to check heart function and for pericardial effusion. Pericardial effusion case studies in ekg pathology. Association accaha committee defined the criteria for low. The most common finding is widespread stsegment elevation, which occurs in the first stage and reverts back to normal in the second. Patients with pericardial effusions may quickly progress to cardiac tamponade.
George nikolic, author of practical cardiology 2nd ed. Electrical alternans is most commonly attributed to pericardial effusion and tamponade pathology. The ecg changes associated with pericardial effusion described in textbooks are based only on small. Until now there was insufficient evidence for strong recommendations in this group of conditions which can severely restrict quality. A 50yearold woman has a syncopal episode as she is walking into her oncologists office. Electrocardiography ecg may reveal signs of pericardial effusion.
Massive pericardial effusion produces a triad of low qrs voltage. Proficiency in electrocardiogram ecg interpretation is an essential skill for medical students, housestaff, and clinicians. Pdf pericardial effusions in patients with end stage renal. For the casecontrol comparisons, patients with effusion had an average heart rate higher than their. Help us keep the lights on and well keep bringing you the quality content that you love. This echocardiogram shows a large amount of pericardial effusion identified by the white arrows. After her episode she states she feels unwell and has vague discomfort. In this example it is best seen in the chest leads where the qrs points in different directions. Pericardial effusion can lead to cardiac tamponade which when left undetected or untreated is fatal. The spectrum of pericardial effusions ranges from mild asymptomatic effusions to cardiac tamponade. New concepts in ecg interpretation alessandro capucci springer. The ecg changes associated with pericardial effusion described in textbooks are based only on small series of human cases and data from animals. The most common finding is widespread stsegment elevation, which occurs in. Appropriate special investigations the following are recommended in all patients with suspected pericarditis.
B acute pleuropericarditis with st segment elevation and sinus tachycardia on ecg strip. Learn more about both conditions including epidemiology, etiology, pathology, pathophysiology, symptoms, diagnosis, therapy and prognosis. Relative decrease in pulmonary vascularity with cardiomegaly may suggest pericardial effusion. Microscopic polyangiitis presenting as a pericardial effusion. Clinical etiolalogical and imaging profile of pericardial. Unlike mi, acute pericarditis does not cause reciprocal depression in st segments except in leads avr and v1, and there are no pathologic q waves. A pericardial effusion with enough pressure to adversely affect heart function is called cardiac tamponade. The complications of pericarditis include pericardial effusion, tamponade and myopericarditis. Learn about pericardial effusion, cardiac tamponade and electrical alternans, with emphasis on ecg, clinical features and causes. Guidelines on the diagnosis and management of pericardial diseases full text the task force on the diagnosis and management of pericardial diseases of the european society of cardiology task force members, bernhard maisch, chairperson germany, petar m. The significance of effusions lies in their relationship to an underlying disease state and in their potential to affect a patients haemodynamics. Electrocardiography pericarditis, pericardial effusion and. A fluid depth of 5mm in the pericardial sac is suggestive of an effusion. Low ecg voltage has been associated with pericardial effusion and has been attributed to the insulating effect of the fluid around the heart.
Low qrs voltage and its causes department of emergency medicine. The clinical value of the ecg in noncardiac conditions. With an interdisciplinary appeal, this book, based on case reports, shows a number of. Advanced imaging techniques can accurately detect and quantify the size of pericardial effusions. One study using limb lead criteria showed that it is more specific for tamponade rather than an effusion. Electrocardiographic low qrs voltage lqrsv has many causes, which can be differentiated. Until now there was insufficient evidence for strong recommendations in this group of. It is a nice size for students to take on clinical rotations. Cardiac tamponade, electrocardiogram, pericarditis. New esc guidelines on pericardial diseases published today 29 august 2015 new esc guidelines on pericardial diseases are.
The ecg in patients with acute pericarditis goes through 4 stages. Echocardiography in evaluation of pericardial disease. The ecg criteria book will be a nice supplement to the main text. Pericarditis post cardiac surgery tuberculosis malignancy eg. Electrocardiography pericarditis, pericardial effusion. Ecg strip showing declining and rising qrs amplitude in a patient with pericardial effusion. The pericardial space cavity always contains a small amount of serous fluid which acts as a lubricant that prevents friction during ventricular contraction and relaxation.
Persistent pr segment change in malignant pericardial disease. A chest xray is done mainly to exclude other important differential. Diagnosis of acute pericarditis european society of cardiology. Which ecg findings are characteristic of pericardial effusion. However, electrical alternans is also associated with other pathologies. Pericardial effusion with cardiac tamponade as a form of presentation of primary hypothyroidism arun agarwal1, nikhil chowdhury2, ankit mathur3, samiksha sharma4, aakanksha agarwal5 abstract hypothyroidism is a rare cause of pericardial effusion pe. Pericardial effusion is a common finding in clinical practice either as incidental finding or manifestation of a systemic or cardiac disease. Chest x ray can show cardiomegaly if sufficient fluid is present. Low voltage of the three ecg signs we examined, low voltage was the one most closely associated with the presence of large and moderate pericardial effusion and with the presence. Patients with this ecg pattern need to be immediately assessed for clinical and echocardiographic evidence of tamponade. New esc guidelines on pericardial diseases are published today. The ecg in acute pericarditis may show abnormalities confined to st and pr segments and t waves, usually in most leads.
Acute pericarditis, the most common pericardial syndrome in clinical practice, is diagnosed based on two of the following criteria. Pericardial effusions in patients with end stage renal disease article pdf available in heart 402. This rhythm is typically associated with pericardial effusion via the swinging heart from the fluid surrounding the heart. In a recent study, no correlation was shown between the volume of. Diagnostic value of electrocardiogram in cardiac tamponade. Methodological ecg interpretation the ecg must always be interpreted systematically. Tamponade is potentially lifethreatening and is diagnosed by the clinical findings of decreased blood pressure, elevated jugular venous pressure, muffled heart. However, medical school and postgraduate resources to develop and upgrade the necessary high level of ecg literacy are severely limited. Because of the limited amount of space in the pericardial cavity, fluid accumulation leads to an increased intrapericardial pressure which can negatively affect heart function. Electrical alternans is defined as alternating qrs amplitude that is seen in any or all leads on an electrocardiogram ecg with no additional changes to the conduction pathways of the heart. Inclusion criteria patients who presented with pericardial effusion including cardiac tamponade based on clinical criteria and confirmed by. The presence of low voltage and sinus tachycardia should always raise concern about pericardial effusion with tamponade.
Pericardial effusion is a frequent finding that occurs due to primary pericardial disease or in relation to a myriad of systemic disease processes. A small amount of fluid in the pericardial sac is a common finding. Overview of pericardial effusion evaluation and workup lab tests ecg, cxr, chest ct complete blood count chemistry profile and renal function thyroid function blood cultures in setting of fever or sepsis antidouble stranded dna, serum complement tuberculin skin test, hiv serologies. Pericardial effusion secondary to hypothyroidism remains a diagnostic challenge for clinicians. The electrocardiogram ecg and radiologic imaging studies are noninvasive and may be helpful when evaluating pericardial effusions, but have low sensitivity and specificity for. Ecg evaluation for pr segment changes is often ignored, but it is an important tool for diagnostic evaluation, especially when used in the appropriate clinical setting.
L no stt elevations in ecg due to the lack of the myocardial inflammation. Amal mattus ecg case of the week september 2, 2019 hpi. It addresses a significant gap in ecg interpretation, which is the actual cause of. Nov 28, 2018 pericardial effusion is the presence of an abnormal amount of fluid andor an abnormal character to fluid in the pericardial space. The interpretation algorithm presented below is easy to follow and it. Ecg findings of low voltage, prsegment depression, and stsegment elevation are not sufficient for identifying pericardial effusions. Jul 14, 2016 malignant pericardial effusions are most commonly seen in active solid tumors such as breast and lung cancer, and hematologic malignancies. In contrast, 12lead electrocardiogram is inexpensive and is easily performed, but to our knowledge, its diagnostic value for pericardial effusion and cardiac tamponade has not been systematically examined. The clinical diagnosis of acute pericarditis is based on simple criteria. Ecg findings in massive pericardial effusion litfl ecg library. Human immunodeficiency virusassociated pericardial effusion. In april of 2011 i presented a case of subtle hyperkalemia. Pericardial effusion is the presence of an abnormal amount of fluid andor an abnormal character to fluid in the pericardial space. Because these ecg findings cannot reliably identify these conditions, we conclude that 12 lead ecg is poorly diagnostic of pericardial effusion and cardiac tamponade.
Low electrocardiographic voltage in pericardial effusion. Clinical presentation with pericardial effusion, ecg changes, elevation of cardiac specific enzymes e. The aetiology is varied infectious, neoplastic, autoimmune, metabolic, and drugrelated, being. It can be caused by a variety of local and systemic disorders, or it may be idiopathic. These changes include low qrs voltage, electrical alternans, p wave changes, and t. Ecg findings in massive pericardial effusion litfl ecg. New esc guidelines on pericardial diseases published today.
Electrocardiographic changes in pericardial effusion david g. An approach to the patient with suspected pericardial disease. Ecg changes in lead avr are generally in the opposite direction of other leads. Persistent pr segment change in malignant pericardial. Pericardial effusion is a relatively common finding in everyday clinical practice. Guidelines on the diagnosis and management of pericardial. With the increasing use of bedside ultrasound, emergency physicians should be able to easily diagnose pericardial effusion. Pdf pericardial effusions in patients with end stage. No correlation between effusion size and heart rate was identified. These include arrhythmias, alteration in conduction, a shift in axis. Pericardial effusion ecg guru instructor resources. These ecg findings are also not specific but may fit in with the diagnosis of pericardial effusion. The most important cause is massive pericardial effusion, which produces a triad of.
I teach ekg interpretation to 4th year medical students and provide each student with a copy of this book. Ecg finding of pericardial effusion with or without cardiac tamponade is low voltage qrs complexes, probably due to shortcrcutng of cardac potentas by the fud surroundng the heart. In addition, when the ecgs indicating effusion from the 46 patients were compared with the ecgs from their age and sexmatched control subjects, differences in heart rate 106 beats per minute vs 80 beats per minute, respectively and small changes in qrs voltage were associated with effusion status. Posts about pericardial effusion written by thejarvik7. For diagnosing pericardial effusion, an echocardiogram is the study to order, not an ecg. L patients on maintenance chronic haemodialysis or peritoneal dialysis can also be affected. Sometimes the clinical picture of the patient leads directly to the search for pericardial effusion, as occurs in patients with chest pain of pericarditic characteristics or in patients with underlying diseases that can cause pericardial involvement renal failure, chest irradiation and thoracic. The ecg guru provides free resources for you to use. How to diagnose pericardial tamponade on bedside echo, part 1 and part 2 from the ultrasound podcast dr smiths ecg blog. Electrocardiographic changes in pericardial effusion. Permissions beyond the scope of this license may be available. This is rarely seen and is due to the heart moving in the effusion.
Pr interval impulse from atria to ventricles to ventricles. The diagnosis of pericardial effusion and cardiac tamponade. Pericardial effusion with cardiac tamponade as a form of. These conditions are often difficult to diagnose, although physical examination and chest radiography are known to be poorly diagnostic of pericardial effusion. The stages of the ecg changes of pericarditis are discussed. Is it common to have normal ecg with pericardial effusion. Aug 29, 2015 new esc guidelines on pericardial diseases are published today. Management of pericardial effusion european heart journal. Electrical alternans is the classic ecg abnormality with pericardial effusion. Etiology the etiology of a pericardial effusion can often be deduced from the clinical presentation box 1. Pericardial effusion is defined as an increased amount of pericardial fluid. Malignant involvement of the pericardium has been detected in up to 20 % of patients diagnosed with cancer 1, 2, and can manifest as pericarditis, pericardial effusion, cardiac tamponade or constrictive pericarditis.
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