The correlation of severity of pericardial effusion with the symptoms, signs and electrocardiographic findings.

Thesis Report.

ABSTRACT:

Objective : To relate the severity of the pericardial effusion and cardiac tamponade with the clinical symptoms, signs and electrocardiographic findings.

Design : A cross-sectional study of thirty-four patients having significant pericardial effusion in echocardiogram. Setting : Patients with effusion admitted under the department of Medicine in Tribhuvan University Teaching Hospital and Kathmandu Medical College. Main outcome measures : • Association of severity of Pericardial effusion with symptoms and signs , by assessing the abilities of symptoms and signs to distinguish patients with large pericardial effusion from patients with small or moderate effusion, and patients with cardiac tamponade from patients without tamponade by measuring p-value and Odds ratio with Chi-square test. • Sensitivity and specificity, predictive values and accuracies of ECG findings: low voltage, PR segment depression and electrical alternans and their diagnostic values. • Association of these ECG findings with large pericardial effusion and cardiac tamponade by using univariate and multivariate analysis. • Association of cardiomegaly and other chest X-ray findings with large pericardial effusion and cardiac tamponade.

Observation : Among fifty patients, who had pericardial effusion in echocardiogram, thirty-four patients were qualified for inclusion in the study. Out of thirty-four patients, seven patients (20.6 percent) had mild or small effusion; ten patients (29.4 percent) had moderate effusion and seventeen patients (50 percent) had large effusion. Six patients (17.6 percent) were in cardiac tamponade clinically as well as in echo findings. An additional patients had echo findings suggestive of tamponade but clinically he had no signs of tamponade. Male to female ratio was 1.1:1. Nearly 23.5 percent of the patients belonged to the age group of 51 to 60 years. Thirteen patients underwent pericardiocentesis, in six patients to relieve cardiac tamponade and in remaining seven for diagnostic purpose. Out of thirteen pericardiocentesis samples, ten (77 percent) were haemorrhagic. Malignant cells were present in cytological examination in four (30.76 percent) samples and AFB was grown in Ogawa media in three (23 percent) samples. 1. Tuberculous effusion - 9(26.5%) 2. Congestive Heart Failure-8 (23.5%) With Diabetes mellitus/Hypertension -7 (20.6%) With valvular heart disease without endocarditis- 1(2.9) 3. Malignancy - 4 (11.7%) 4. Renal impairment - 4 (11.7%) 5. RHD with SABE - 2 (5.88%) 6. Post traumatic / injury - 2 (5.88) -post mitral valve replacement - post DC shock 7. Connective tissue disease ( RA, SLE) - 2 (5.88%) 8. Post myocardial infarction 9. Idiopathic chronic pericardial effusion - 1 (2.9 %) The duration of symptoms ranged from seven days to two years. Clinical Symptoms Thirty-two patients (94 percent)had breathlessness with 14 (41.17 percent) patients in NYHA class IV, 8 (23.53 percent) patients in class III, 6 (17.64 percent), patients in class II and 4 (11.76 percent) in class I. There was an association of large effusion with degree of breathlessness with significant p value of 0.01 by Chi-square test. Other common symptoms were fatigue (85.3 percent), cough (76.47 percent), anorexia (70.58 percent), pedal oedema (58.82 percent), fever (55.88 percent), andominal pain (52.94 percent), nausea and vomiting (44.11 percent), chest pain (29.4 percent) and syncope (5.9 percent). Among ten (29.4 percent) patients with chest pain, three had angina type of chest pain, three had pericarditic chest pain and four had non-specific chest pain. The patients with most of these symptoms belonged to large effusion group (Bar diagram). The large effusion was associated with the presence of cough, fever and anorexia with statistical significance (p value <0.05). The chance of getting large effusion in the presence of cough, fever or anorexia in patients with pericardial effusion is more than the chance of getting large effusion in the absence of cough, fever or anorexia. This finding can be explained by the commonest aetiology of pericardial effusion in this study - tuberculosis that can cause all three symptoms and thus associated with large effusion. The presence of cardiac tamponade was not significantly associated with presence of above symptoms (p value >0.05). Clinical Signs The most common physical finding was tachypnoea (67.64 percent) followed by raised jugular venous pressure, pedal oedema, heaptomeglay, pallor, tachycardia, muffled heart sounds, Ewart's sign, fever, hypertension, pericardial friction rub, pulsus paradoxus, Kussmaul's sign, cyanosis and icterus. The presence of large effusion was significantly associated with hypotension (p value 0.06), tachypnoea (p value 0.03), pulsus paradoxus (p value 0.01), muffled heart sounds (p value 0.03) and Ewart's sign (p value 0.03). Similarly the presence of hypotension, pulsus paradoxus, cyanosis, muffled heart sounds and Ewart's sign were associated with the presence of cardiac tamponade (p Value <0.05). Chest x-ray In the chest x-ray, cardio-thoracic ratio was more than 0.50 in 88.3 percents with mean ratio of 0.64 with standard deviation of 0.10. The large effusion was associated with left pleural effusion (p value 0.04) and cardiac tamponade was associated with bilateral pleural effusion ( p value 0.02). ECG Findings In electrocardiographic findings, sinus tachycardia was present in 61.76 percent of subjects. Low voltage was present in 38.2 percent, PR-segment depression in 6 percent and electrical alternans in 9 percent subjects. In a control group without effusion in echocardiograms, only 6 percent had low voltage and more had PR-segment depression and electrical alternans. Among these three signs, low voltage and electrical alternans were associated with large effusion and cardiac tamponade. Between these two signs, low voltage was closely associated with large effusion with statistical significance (p value of 0.01).

Conclusion : The common symptoms of pericardial effusion were dyspnoea, fatigue, cough, anorexia, pedal oedema, fever, abdominal pain, nausea and chest pain. The patients with most of these symptoms belonged to large effusion group. The large pericardial effusion was significantly associated with presence of cough, fever and anorexa. If cough, fever and anorexia are present in a patient with pericardial effusion, we can guess that he/she has large amount of effusion. These symptoms are the common manifestations of tuberculosis, which was the commonest aetiology of effusion in this study. Among signs, the presence of hypotension, tachypnoea, pulsus paradoxus, muffled heart sounds and Ewart's sign were associated with large effusion with statistical significance. The presence of hypotension, pulsus paradoxus, cyanosis, muffled heart sounds and Ewart's sign were also significantly associated with cardiac tamponade. Among ECG signs, low voltage and electrical alternans are suggestive but not diagnostic of large effusion and cardiac tamponade. Only low voltage is closely associated with the presence of large effusion.

Eng.