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EVALUATION OF ETIOLOGY, CLINICO-PATHOLOGICAL PRESENTATION AND OUTCOME OF PERICARDIAL EFFUSION.

Byline: Muhammad Kashif, Tanvir Ahmad Raja, Adeel Ur Rehman, Azhar Mehmood Kiyani, Faizania Shabbir and Tausif Ahmed Rajput

ABSTRACT

Objective: To quantify the common causes and clinical presentation of pericardial effusion and its outcome.

Study Design: Descriptive study.

Place and duration of study: Rawalpindi Institute of Cardiology, Rawalpindi for a period of one year.

Material and Methods: A total of 63 cases of pericardial effusion confirmed by clinical complaints and echo-cardiography were enrolled. Etiology of disease, clinical presentation and management outcome were observed. The patients were consented for participation in the study. Consent was taken from patients. SPSS 17.0 was used to analyze data.

Results: The mean age of patients was 43.9 years with male predominance (61.9%). Leading cause of disease was infectious tuberculous 47 (74.6%), followed by malignant cause 5 (7.9%). Fever 33 (52.3%), shortness of breath 38 (60.3%) and chest pain were main complaints. Conservative management with ATT was given in 38 (60.3%) whereas majority of the patients were managed with pericardiocentesis 53 (84.1%). Majority 59 (93.6%) improved and discharge whereas 3 (4.6%) died and 1 (1.5%) patient suffered recurrence.

Conclusions: The leading cause of pericardial effusion was infectious tuberculous in this study. Breathing difficulty, chest pain, fever and cough were the common presenting complaints. Majority of patients were managed with ATT + pericardiocentesis and they improved and got discharged.

Keywords: Clinical complaints, Etiology, Outcome, Pericardial effusion.

INTRODUCTION

Pericardial effusion presents relatively commonly in clinical practice1. It is a significant cause of cardiac malfunction and could lead to tamponade due to accumulation of fluid in cardiac sac. Its effect on heart depends on the size of effusion and fluid volume. Pericardial effusion is attributed to underlying diseases like tuberculosis, malignancy or other viral conditions, however, in many instances the cause is unknown and thus, present as idiopathic pericardial effusion2. In the western world malignancy is the major cause of pericardial effusion whereas in the developing and under developed world infectious causes like TB are still common underlying condition2,3.

Thoracic x-ray shows the presence of an enlarged cardiac silhouette with clear lungs and at times is non-specific. Echocardiography is the baseline investigation to determine the presence of pericardial effusion, it is also prioritized due to its distinctive strength to measure the size and volume of fluid4. In cases of mild pericardial effusion (<10 mm space in sac) is though very frequent specially in women, it is at times misjudged and can be accurately screened for its nature and intensity by a CT scan or a more in-depth MR imaging4,5.

There are numerous management strategies for pericardial effusion; conservative management, pericardiocentesis and surgical options. The outcome of any treatment lies on the intensity of effusion and any specific co-morbid condition6. Pakistan being a lower middle income developing country has plenty of infectious risk attributable social and environmental conditions. Pericardial effusion is a frequent presentation but its observation and study has been a neglected affair so far, specially, in the underdeveloped world. There is no or very few pervious data regarding this topic from national and local level settings. Thus, we aimed to determine the etiological background of pericardial effusion and outcome of its management in an exclusive cardiac facility of the country.

Table-I: Demographic characteristics of study patients (n=63).

Demographic characteristics###No. of cases###Percentage (%)

Age (years)

15 to 20###7###11.1

21 to 30###13###20.6

31 to 40###11###17.4

41 to 50###6###9.5

51 to 60###13###20.6

61 or above###13###20.6

Mean +- SD###43.9 +- 18.8

Gender

Male###39###61.9

Female###24###38.1

Table-II: Etiology of disease in study patients (n=63).

###No. of cases###Percentage (%)

morbidities

Infectious###47###74.6

Malignancy###5###7.9

CRF###4###6.2

SLE###2###3.1

Post PCI###1###1.5

TPM###1###1.5

Co-morbidities

Hypertension/AF###1###1.5

Hypothyroidism###1###1.5

VSD###1###1.5

MATERIAL AND METHODS

A descriptive study was conducted in the Rawalpindi Institute of Cardiology, Rawalpindi for a period of one year from April 2016 to April 2017. A total of 63 pericardial effusion patients were selected and enrolled. An informed consent was administered to those fulfilling the study inclusion criteria. The etiological background and clinical presentation of patients was noted. The status of pericardial effusion on the basis of ECHO and biochemical parameters was also noted. The management strategies and their final outcome in terms of improvement, recurrence and death were also noted.

The patients comprised of adult cases above 15 years of age and both genders. Patients with signs and symptoms of pericardial effusion confirmed on echocardiogram were included. Those below the age of 15 years and having any associated cardiac co-morbidity were excluded from the study. The study sample was 59 calculated through WHO sample size calculator; based on 95% confidence level, alpha error of 5% and anticipated population with pericardia effusion of 4% (ref), after including a 5% non-response rate. Sampling was done through non-probability consecutive sampling. The data was analyzed using SPSS software version 20.0. Descriptive statistics was applied to measure frequency and percentages from categorical variables like etiology, clinical presentation and management outcome and mean and standard deviation from quantitative numerical variables like age of patients and biochemical laboratory parameters like ESR, hemoglobin and TLC levels.

RESULTS

The mean age of stud patients was 43.9 +- 18.8 years with almost equal distribution in all decades of life ranging from 15 years to up to 80 years. Male gender was in majority with (61.9%) proportion (table-I). In most of the patients the etiology of disease was infectious tuberculous 47 (74.6%), followed by malignant in 5 (7.9%), CRF in 4 (6.2%) and other frequent causes were SLE 2 (3.1%) and co-morbidities like hypertension, hypothyroidism and VSD in 1 (1.5%) patient each (table-II). The most frequent signs and symptoms in patients were fever 33 (52.3%), shortness of breath 38 (60.3%) and chest pain in 20 (31.7%) patients. The other presenting complaints noted in the study were cough 17 (26.9%) and cardiac tamponade seen in 4 (6.3%) cases (figure).

The size of pericardial effusion was found large in 37 (58.7%) patients, in 9 (14.2%) it was moderate size whereas size was normal in 17 (26.9%) patients. The location of the pericardial effusion was almost circumferential in all study cases. The average ESR was 44.5 +- 12.1 and hemoglobin level was 11.7 +- 2.7 mg/dl. In 19 (30.1%) cases the pericardial fluid was exudative lymphocytic, in 5 (7.9%) cases it was bacterial while in 2 (3.1%) patients it was transudative lymphocytic. Medical ATT + pericardiocentesis was given to 38 (60.3%), Antibiotics + pericardio-centesis given to 15 (23.8%) whereas 12 (19.0%) patients were managed with pericardiocentesis alone (table-III).

The majority of the patients 59 (93.6%) improved and were discharged from hospital, however, there were 3 (4.6%) deaths and 1 (1.5%) patient had recurrence of pericardial effusion (table-IV).

DISCUSSION

To date this is one of the earliest observations of pericardial effusion from Pakistan in terms of etiology, clinco-pathological presentation and management outcome. The scientific literature on this topic is not commonly available internationally. A total of 63 patients were analyzed in this trial and the main cause of pericardial effusion was infectious tuberculous (up to 80.0%) and malignant in (8.0%) cases. A study from India on children witnessed a similar trend where tuberculosis was the main cause of pericardial effusion7. Similarly, Guven et al from Turkey reported tubercular etiology in 30% of their cases8. However, most of previous reports from developed world have in contrast finding and the current study clearly shows a deviation from those reports.

Studies by Corey et al and Colombo et al witnessed idiopathic and neoplasm causes as the main factors of pericardial effusion in their patients followed by less frequent cause like uremia and TB9,10. Similarly, Sagrista-Sauleda et al also witnessed neoplasm and idiopathic nature as the most frequent causes of pericardial effusion followed by uremia, TB and other factors11. These etiologic findings are in contrast to our study results where the main reasons were infectious TB whereas malignancy and others appeared to be less significant causative agents. The final etiology of pericardial effusion should be based on specific data, in this regard simpleclinical complaints may be useful. A previous report observed that hemodynamic compromise, cardiomegaly, pleural effusion, and a large pericardial effusion were significantly found in patients with tuberculous or malignant pericardial disease12.

The difference in etiology is attributed to the geographic, socioeconomic and environmental factors. The causes are viral or non-communicable in developed world and TB in the developing and under developed world. The etiology in current study is not surprising as Pakistan is still one of the few countries where Tuberculosis is epidemic. In the present study the clinical findings are continuous with previous literature in terms of patients having breathlessness, fever and chest pain, however, cough was also noted as a main complaint. Previous reports also establish these complaints commonly associated with pericardial effusion7,13.

In the current study, most patients had large size of pleural effusion and location was circumferential in almost all. Similarly, the biochemical investigation of hemogloblin was found in normal range, whereas TLC and ESR were found raised indicative of infection. A previous study by Ilan Y found similar findings of hemoglobin and hematocrit in their pericardial effusion patients. It is natural that the disease brings biochemical derangement in majority of patients13. Medical treatment + pericardiocenteris was given to (60.0%) cases in this study, however, almost one fifth were given antibiotic + pericardiocentesis and one fifth were managed with pericardiocentesis alone. We noted treatment success in (93.6%) study cases, recurrence occurred in 1 (1.5%) case whereas there were 3 (4.6%) deaths which were attributed to underlying medical condition like malignancy and CRF whereas one patient died due to post PCI effusion in the present study.

Bastian reported from his series of cardiac tamponade patients undergoing primary pericardiocentesis, had a success rate of 81% and a recurrence rate of 19%14. A high mortality (8.3%) and complication (16.6%) rates were witnessed by Onem et al after percutaneous catheter drainage in the management of cardiac tamponade15.

In patients with massive idiopathic chronic pericardial effusion, pericardiocentesis is recommended because of the chances of unexpected overt tamponade. Moreover, simple pericardiocentesis alleviates symptoms in majority of patients, however, pericardial effusion could recur in as many as 40%-50% cases16. It has been suggested by many that pericardiocentesis or percutaneous tube drainage could be a useful management for patients with acute tamponade17. Conservative management in tuberculous infectious pericardial effusion has its own merits for the underlying condition and patients had significant improvement. The prognosis of pericardial effusion depends on underlying etiology, in cases with malignant causes and involvement of lungs and other closely located abdominal parts there is a risk of poor outcome.

The cases with tuberculous infectious pericardial effusion the outcome is better with first conservative management and then drainage of effusion. In recurrent cases surgical options like pericardectomy can deal best.

Table-III: Findings on investigations and management strategy in the study (n=63).

Findings###No. of cases###Percentage (%)

Findings on echo

Size

Large###37###58.7

Moderate###9###14.2

Normal###17###26.9

Location

Circumferential###pericardial###61###96.8

effusion

Circumferential effusion with###2###3.1

tamponade

Signs of tamponade###12###19.0

Lab findings

ESR###44.5 +- 12.1

Hemoglobin###11.7 +- 2.7

Pericardial fluid analysis

Exudative lymphocytic###19###30.1

Bacterial###5###7.9

Transudative lymphocytic###2###3.5

Management

Medical###ATT###+###38###60.3%

Pericardiocentesis

Antibiotics + Pericardiocentesis###15###23.8%

Pericardiocentesis alone###12###19.0%

Table-IV: Outcome of patients (n=63).

Outcome###No. of cases###Percentage (%)

Improved and discharge###59###93.6 %

Death###3###4.6 %

Recurrence###1###1.5 %

CONCLUSION

As per our findings the leading cause of pericardial effusion was infectious tuberculous in this study. Breathing difficulty, chest pain, fever and cough were the common presenting complaints in our study. Majority of patients were managed with medical ATT + pericardiocentesis. Most of the patients improved and were discharged in recovered state whereas 3 patients died not mainly due to pericardial procedure but underlying malignancy and renal failure. Keeping the lethal nature of pericardial effusion, there is a need to observe these patients and intervene in time so that the risk of mortality can be averted.

ACKNOWLDEGEMENT

We are thankful to the hospital management and patients for their cooperation and provision of data to carry out this study.

CONFLICT OF INTEREST

This study has no conflict of interest to declare by any author.

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Publication:Pakistan Armed Forces Medical Journal
Geographic Code:9PAKI
Date:Feb 28, 2018
Words:2825
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