Pericardial effusion and left ventricular dysfunction associated with ascites secondary to hepatic cirrhosis

Fluid retention in decompensated hepatic cirrhosis is frequently accompanied by edema, ascites, and hydrothorax. Whether pericardial effusion occurs in such patients has not been studied. Twenty-seven consecutively hospitalized patients with ascites secondary to alcoholic cirrhosis of the liver were studied, and 28 control subjects were studied with the use of an echocardiographic method to detect pericardial effusion and to evaluate their left ventricular (LV) function. Seventeen patients (63%) and three control subjects (11%) showed pericardial effusion. The prevalence of pericardial effusion in the patients was significantly greater than in the control subjects (chi 2 = 10.6). Although the mean values of the echocardiographic measurements of LV function of the patients and the control subjects did not differ significantly, the individual values of the patients varied considerably. Among the patients, six patients (27%) had LV dysfunction, 14 patients (64%) had normal values, and two patients (9%) had values suggestive of hypercontractility of the left ventricle. Furthermore, abnormal systolic motions of the mitral valve and/or septum were noted in eight patients (30%) but in none of the control subjects. Six patients with pericardial effusion on initial examination were evaluated after the resolution of their ascites; pericardial effusion disappeared in two patients, diminished in two others, and remained unchanged in two patients. Resolution of ascites was also associated with normalization of the systolic motion of the mitral valve and septum. It was concluded that pericardial effusion is common in patients with ascites secondary to alcoholic hepatic cirrhosis and that its presence is probably related to fluid retention.     

Inter‐ and Intraobserver Variability in LVH and RVH Reporting in Pediatric ECGs

Background: Physicians' diagnoses are often used as the gold standard for evaluating computer electrocardiogram (ECG) interpretation programs. As part of a larger study to evaluate the Glasgow pediatric ECG analysis program, inter‐ and intraobserver variability in the ECG reporting of two pediatric cardiologists was examined. Methods: The ECGs of 984 children were sent for reporting independently by two cardiologists with all identifying information except age and sex removed. Three hundred twenty ECGs had no clinical indication available, and they were thus reported “blind.” For 664 ECGs, the clinical indication was known and included with the ECG trace. All ECGs reported as right ventricular hypertrophy (RVH) or left ventricular hypertrophy (LVH) were returned to the cardiologists without their knowledge for reporting a second time “blind” as to the clinical indication. Results: When the cardiologists' reports were compared with each other, the provision of clinical information led to greater agreement between them for the diagnosis of LVH (kappa increased from 0.44 to 0.52) but did not substantially affect their agreement in diagnosing RVH (kappa fell from 0.66 to 0.63). Intraindividual comparisons in 166 ECGs revealed that one cardiologist was more consistent in diagnosing RVH and the other more consistent in diagnosing LVH. Conclusions: This study has demonstrated the difficulties in using cardiologists' diagnoses as the gold standard with which to evaluate pediatric ECGs.     

Electrocardiographic patterns of patients with echocardiographically determined biventricular hypertrophy.

The numerous criteria proposed for the electrocardiographic (ECG) diagnosis of biventricular hypertrophy (BVH) suffer from inadequate correlative data. We used two-dimensional (2D) echocardiography to identify BVH and analyzed the ECG patterns in these patients. The study group had 69 such patients with BVH and the control group had 22 patients with isolated left ventricular hypertrophy (LVH) demonstrated by 2D echocardiography. The electrocardiograms were analyzed for the presence of established criteria used in the diagnosis of LVH and right ventricular hypertrophy (RVH). Of the 69 patients in the study group, 17 (25%) had ECG findings of BVH, 25 (36%) had LVH, and 14 (20%) had RVH. An S wave in V5/V6 of >7 mm was most the frequent finding in the 17 patients with BVH on the electrocardiogram. The sensitivity of ECG criteria for BVH was 24.6%, specificity was 86.4%, and positive predictive value was 85%. This study reemphasizes the difficulty of ECG diagnosis of BVH. The electrocardiogram has a low sensitivity but satisfactory specificity and positive predictive accuracy for BVH.     

The heart and ankylosing spondylitis

We studied 40 consecutive patients with Ankylosing Spondylitis from the cardiological point of view through non-invasive methods. Fourteen (35%) patients had some kind of cardiovascular complication as shown by any of the used methods. a) Symptoms: fifteen (37.5%) refered nonspecific chest pain, five (12.5%) dyspnea on exertion and four (10%) frecuent palpitations. b) Physical Examination: two patients (5%) had aortic regurgitation and two (5%) mitral valve disease. c) Electrocardiogram: in seven (17.5%), left ventricular hypertrophy was detected, in two (5%) left atrial hypertrophy and in seven (17.5%) some type of conduction disturbance. d) Chest X Ray: six (15%) had left ventricular hypertrophy, one (2.5%) left atrial hypertrophy and two (5%) dilated ascending aorta. e) Echocardiogram: two cases (5%) had aortic dilatation and other two (5%), mitral valve disease. In three patients (7.5%) pericardial effusion was found, which in our series, it is more frecuent than has been reported up until now in the literature.     

Comparison of Target Organ Damage in Renovascular and Essential Hypertension

In many reports, the prevalence of target organ damage in renovascular hypertension (RVH) appears to be higher than in essential hypertension (EH). Since in most studies the renal artery stenosis is part of a diffuse atherosclerotic disease, it is not known whether these complications are due to RVH itself or to the vascular disease.We have undertaken a case control study of 92 patients divided into two groups (46 in each), one with RVH and the other with EH and abdominal aortic aneurysm, with a comparable degree of diffuse atherosclerotic vascular disease. The vascular state of the extracranial carotid arteries and abdominal and inferior limb districts was investigated with angiography and sonography. The prevalence of left ventricular hypertrophy (LVH) and ischemic heart disease (IHD) were assessed by electrocardiography. Serum creatinine and urinary protein excretion were employed in the renal evaluation. While the analysis of the results confirmed an even diffusion of atherosclerotic vascular disease between the two groups, a significant difference was found in the prevalence of heart and renal damage. LVH was present in 32.6% of RVH patients versus 10.8% in EH (P = .02). Serum creatinine > 1.4 mg/dL was found in 50% of RVH and in 23.9% of EH, (P = .01). The prevalence of proteinuria in RVH was also higher although not reaching the statistical significance. The results suggest that, in patients with comparable degrees of atherosclerotic vascular disease, RVH is responsible for the higher prevalence of target organ damage in this condition compared to those with EH. Am J Hypertens 1996;9:1062–1067     

Integral indices of the automatically reproduced spatial QRS loop in the diagnosis of different forms of myocardial hypertrophy

A total of 249 patients with arterial hypertension taking a variety of clinical forms, primary pulmonary hypertension, dilatation cardiomyopathy, congenital heart diseases with secondary pulmonary hypertension were examined and allocated to 3 groups: 125 patients with left-ventricular hypertrophy (LVH) (group 1); 44 patients with right-ventricular hypertrophy (RVH) (group 2), and 80 patients with combined hypertrophy of both ventricles (CH). Eighty-one normal subjects were taken as controls. New parameters of diagnostic significance were identified by automated reproduction of vectorcardiographic spatial QRSxyz loop (the Macfee-Parungao system) and computer analysis of vectorcardiographic parameters, that improve electrocardiographic diagnosis of cardiac hypertrophies, as compared to the conventional criteria, bringing its accuracy to 88.8% for LVH, 100% for RVH, and 45% for CH. Typical features of myocardial hypertrophy at large are increased area enclosed by the spatial loop (SQRS greater than 3.4 mV2) and/or increased mean vector (LQRSxyz greater than 0.76 mV), while Lx greater than 0.6 mV and/or Lz less than -0.4 mV were specific for LVH; Lx less than 0.05 mV was specific for RVH, and the H angle ranging from -70 degrees to -140 degrees or H of -60 degrees to -140 degrees at Lz less than 1.1 mV, or -50 degrees to -140 degrees at Lz less than 1.5 mV were specific for CH.     

计算机心电图与计算机心向量图的联合应用

本研究利用两个计算机自动诊断系统，一个对心电图，一个对心电向量图进行分析，完成了对国际标准心电图库的联合诊断，产观察了单独诊断之间，单独诊断与联合诊断之间的差异，以进一步探讨心电图与心电向量图在诊断上的互补效应，以及ＣＳＥ研究中关于联合诊断优于单独诊断的机制。国际标准心电图库由１２２０个病例构成，其中正常者３８２例，左室肥大１８３例，右室肥大５５例，双室肥大５３例，前壁心梗１７０例，下壁心梗２７３     

Technetium-99m stannous pyrophosphate myocardial scintigrams in pericardial disease

Technetium-99m stannous pyrophosphate (^99mTc-PYP) myocardial scintigrams were obtained in 35 acute pericarditis and in three chronic constrictive pericarditis patients. Thirteen of 35 acute pericarditis patients (37%) and one of three chronic constrictive pericarditis patients (33%) had abnormal scintigrams (a diffuse pattern in eight patients and a regional pattern in six patients). Of the 17 acute pericarditis patients with classic ST-segment changes of acute pericarditis, 10 (56%) had abnormal scintigrams compared to three of 17 patients (18%) without these ECG change (P < 0.02). These data indicate that pericardial disease may cause an abnormal scintigram. Therefore, one must rule out pericardial disease before concluding that a positive scintigram is due to acute myocardial infarction.     

Tuberculous pericardial effusion--mediastinal lymph glands: the cause and clue to the etiology

BACKGROUND: Tuberculous pericardial effusion is most often due to the spread of tuberculosis from the mediastinal lymph glands; however, no attempt has yet been made to study these glands. We studied the mediastinal glands in proven tuberculous pericardial effusion patients and hypothesized that the findings may be of use in the etiological diagnosis of pericardial effusion. METHODS AND RESULTS: We studied 45 patients with large pericardial effusion or tamponade. All underwent chest computed tomographic studies that were reviewed by radiologists blinded to the diagnosis. Of these 45 patients, 27 had tuberculosis and 18 had viral or idiopathic effusion. Pericardial biopsy was done in 25/27 and tuberculin skin test in 22/27 patients with tuberculosis, and all received specific treatment. In patients with tuberculosis the skin test measured 17+/-3.3 mm. All 27 had mediastinal lymph glands > or = 10 mm in size. The mean size of the mediastinal glands was 19.5+/-8.6 mm and the mean number was 2.5+/-1.2. The aortopulmonary glands were the most frequently enlarged (63%), and hilar the least often (14.8%). The glands showed a hypodense center in 52% of the patients. On follow-up of 15.8+/-10.4 months, glands were not seen in 80.9%, and were smaller in size in 19%; none had a hypodense center. Marked lymphadenopathy was not seen in any patient with viral/idiopathic pericardial effusion. Two had glands < or = 5 mm in size. CONCLUSIONS: Only patients with tuberculosis had substantial mediastinal lymph gland enlargement and not those with viral or idiopathic pericardial effusion. Such glands disappeared or regressed on treatment. In the appropriate clinical context, marked nonhilar mediastinal lymphadenopathy on chest computed tomographic studies along with a strongly positive tuberculin skin test could be of value in the noninvasive diagnosis of pericardial effusion due to tuberculosis.     

Evaluation of children with a large pericardial effusion and cardiac tamponade

OBJECTIVES: Large pericardial effusions and cardiac tamponade are rare in childhood.The aim of this study was to evaluate the aetiological factors and clinical findings of large pericardial effusion and cardiac tamponade in children. METHODS: We reviewed retrospectively the records of 10 (6 male, 4 female) patients (mean age: 8.05 +/- 4.4 y) with the diagnosis of large pericardial effusion and cardiac tamponade requiring pericardiocentesis and pericardial drainage between 2002 and 2004. RESULTS: After extensive diagnostic investigation we detected that three patients had tuberculosis, one patient had uraemic pericarditis; one patient had bacterial pericarditis; one patient had post-pericardiotomy syndrome; two patients had malignancy and two patients had no identifiable aetiology. Echocardiography-guided percutaneous pericardial puncture and pigtail catheter placement is safe and effective for initial treatment of patients with large pericardial effusion and cardiac tamponade and in most cases, initial assessment with clinical, serologic, and radiologic investigation and careful follow-up can reveal the aetiology. CONCLUSIONS: Although tuberculosis is rare in industrialized countries, in developing countries it remains one of the most important causes of large pericardial effusion and should be investigated and excluded in each patient.     

Right ventricular echocardiographic, vectorcardiographic and electrocardiographic study in cor pulmonale

An echocardiographic (echo), vectorcardiographic (VCG) and electrocardiographic (ECG) study of the right ventricle was carried out in 27 patients with chronic obstructive pulmonary disease and cor pulmonale. The subxiphoid echocardiographic approach was applied in all patients. The right ventricular internal diameter index (RVIDd), anterior right ventricular wall thickness (RVWT) and the ratio (R) intraventricular septum thickness/anterior right ventricular wall thickness were statistically different in the 27 patients compared to the 33 normals. All 27 patients had a RVIDd greater than 1.33 cm while in only 17 (63%, P less than 0.01) of these was right ventricular hypertrophy (RVH) detected with VCG or ECg criteria. In 20 patients the RVWT was measured and in 19 of these the RVWT was greater than 0.56 cm. In only one patient was the RVWT less than 0.56 cm. VCG or ECG criteria showed RVH in only 14 (70%) of these patients. The R was measured in 18 patients. All patients had R less than 1.99 and in only 12 (67%, P less than 0.01) of these was RVH diagnosed with VCG or ECG criteria. It seems that the RVIDd, the RVWT and the R are useful indexes for the detection of right ventricular dilatation and hypertrophy. Therefore echocardiography is superior to the conventional ECG and VCG in the recognition of right ventricular hypertrophy and dilatation.     

Evaluation of frontal plane QRS loop rotation in vectorcardiographic diagnosis

The diagnostic usefulness of frontal plane QRS loop rotation in the Frank vectorcardiogram (VCG) was evaluated in a series of 598 normal subjects, 301 patients with postero-diaphragmatic myocardial infarction (PDMI), 84 with lateral myocardial infarction (LMI), 844 with left ventricular hypertrophy (LVH), and 190 with right ventricular hypertrophy (RVH). In normals 62% showed clockwise (CW) rotation of the QRS loops; 28%, figure-of-eight; and 10%, counterclockwise (CCW). The respective distributions were 68%, 23%, and 9% in PDMI; and 23%, 40%, and 37% in LMI. In normals the superior and inferior limits (96% range) of the maximal QRS vector angles were +15° and +79° in VCGs with CW rotation, +12° and +62° in VCGs with figure-of-eight, and −4° and +58° in VCGs with CCW rotation. Based on these limits, approximately half of PDMI cases (with 2% false positives) and a little over two-thirds of LMI cases (with 4% false positives) could be separated from normal. In LVH and RVH groups without clinical evidence of ischemic heart disease, the superior and inferior limits (96% range) of the maximal QRS vector angles differed from those of normal. In LVH such limits were +1° and +86° in VCGs with CW rotation, +12° and +62° in VCGs with figure-of-eight, and −86° and +48° in VCGs with CCW rotation. The respective limits in RVH were +13° and −160°, −3° and +76°, and −30° and +65°. Thus, when LVH or RVH is present, the foregoing limits separating PDMI or LMI from normal need to be modified accordingly.Results of the study demonstrate the diagnostic significance of QRS rotation analysis in the frontal plane VCG. These findings should prove useful as the standard of reference for clinical interpretation of the Frank VCG.     

689例心包积液病因及误诊分析

目的：分析心包积液病因变化及误诊原因。方法：病例回顾分析。结果：结核性、非特异性、肿瘤性、心力衰竭性及尿毒症性心包积液分别占６８９例心包积液的２５．５％、１２．６％、１２．２％、６．５％和６．１％，其他各种原因所致者合计占３７．１％。结核性心包积液由８０年代中期以前的２９．０％降至８０年代中期以后的２２．３％（Ｐ＜０．０５），而肿瘤性心包积液则由９．９％升至１４．１％（Ｐ＜０．０５）。结论：结核性心包积液比例明显下降，而肿瘤性心包积液所占比例则明显上升。心包积液病因误诊主要是将肿瘤性心包积液误诊为其他性质心包积液     

Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s?

STUDY OBJECTIVES: The decrease in incidence of tuberculosis, along with the increase in invasive cardiovascular procedures, may have changed the frequency of causes of bloody pericardial effusion associated with cardiac tamponade, although this is not yet recognized by medical textbooks. We analyzed the causes of bloody pericardial effusion in the clinical setting of cardiac tamponade in the 1990s; patients' survival; the effect of laboratory results on discharge diagnosis; and how often bloody pericardial effusion is a presenting manifestation of a new malignancy or tuberculosis. DESIGN: Retrospective, observational, single-center study. SETTING: A community hospital. PATIENTS: The charts of all patients who underwent pericardiocentesis for cardiac tamponade and had bloody pericardial effusion were retrospectively reviewed. RESULTS: Of 150 patients who had pericardiocentesis for relieving cardiac tamponade, 96 patients (64%) had a bloody pericardial effusion. The most common cause of bloody pericardial effusion was iatrogenic disease (31%), namely, secondary to invasive cardiac procedures. The other common causes were malignancy (26%), complications of atherosclerotic heart disease (11%), and idiopathic disease (10%). Tuberculosis was detected as a cause of bloody pericardial effusion in one patient and presumed to be the cause in another patient. Bloody pericardial effusion was found to be a presenting manifestation of a newly diagnosed malignancy in two patients. The patients in the idiopathic and iatrogenic groups were all alive and had no recurrence of pericardial effusion at 24 +/- 27 and 33 +/- 21 months after hospital discharge, respectively, whereas 80% of patients with malignancy-related bloody effusions died within 8 +/- 6 months. CONCLUSIONS: In a patient population that is reasonably representative of that in most community hospitals in the United States, the most common cause of bloody pericardial effusion in patients with signs or symptoms of cardiac tamponade is now iatrogenic disease. Of the noniatrogenic causes, malignancy, complications of acute myocardial infarction, and idiopathic disease predominated. Hemorrhagic tuberculous pericardial effusions are uncommon and may likely reflect a low incidence of cardiac tuberculosis in community hospitals in the United States.     

Echocardiographic findings of pericardial involvement in patients with malignant pleural mesothelioma with a history of environmental exposure to asbestos and erionite

OBJECTIVE: The aim of the present study was to evaluate the pericardial involvement in patients with malignant mesothelioma caused by exposure to different minerals. METHODOLOGY: Forty-two patients (mean age of 52 +/- 12 years) with malignant mesothelioma were examined with transthoracic echocardiography. Thirty-three (78.9%) patients had a history of environmental exposure to asbestos and nine (21.4%) had a history of environmental exposure to erionite. RESULTS: In 19 (45.2%) patients with malignant pericardial mesothelioma, pericardial involvement was determined by echocardiography. The other 23 (54.8%) patients had no pericardial involvement. Pericardial effusion was detected in nine (64.3%) patients and pericardial effusion was small in six (14.3%) patients, moderate in one (2.4%) patient and large in two patients. Thickening of the pericardium was observed in eight (19%) patients. In another two (7.1%) patients pericardial calcification was observed. Among the 33 patients who had been exposed to asbestos, 15 (45.5%) had pericardial involvement, and among the nine patients with a history of exposure to erionite, four (44.4%) had pericardial involvement. There was no difference in terms of pericardial involvement in different stages of the tumour (P > 0.05). CONCLUSIONS: Pericardial involvement is commonly seen in patients with malignant mesothelioma. Among patients exposed to asbestos or zeolite there was no difference in terms of pericardial involvement. Furthermore, pericardial involvement was not related with the stage of the tumour.     

Specific electrocardiographic features associated with Cushing's disease

Objective Hypercortisolaemia is associated with an increased risk of cardiovascular disease (CVD), either through a direct action on the myocardium or by increased traditional cardiovascular risk factors. The aim of this study was to investigate whether the alterations in the ECG in Cushing’s disease (CD) are predictable from risk factor analysis alone. Design In 79 patients with a diagnosis of CD, retrospectively recruited, ECG features [corrected for heart rate QT (QTc), QTc dispersion (QTcd), left ventricular hypertrophy (ECG‐LVH), right ventricular hypertrophy (ECG‐RVH)], systolic (SBP) and diastolic (DBP) blood pressure were assessed. Biochemical, hormonal (cortisol at 09·00 h or cortisol day curve, CDC) and carbohydrate abnormalities (CHA), history of hypertension and cardiovascular disease were recorded. For comparison reasons, a group of 42 healthy subjects matched for gender, age and body mass index previously subjected to ECG assessment were selected. Results In patients with CD, we noted the following prevalence: metabolic syndrome 39%, hypertension 81%, CVD 21·5%, hypercholesterolaemia 37%, hypertriglyceridaemia 29%, CHA 41%, but a history of cardiac dysrhythmia was only noted in a single patient. No difference in QTc or QTcd was shown between patients with normal or low potassium levels. QTcd >50 ms was associated with both increased ECG‐LVH and ECG‐RVH. When compared to the control group, patients had longer QTcd (P < 0·001), more prevalent LVH (P < 0·001) and RVH (P = 0·001), and higher SBP and DBP (P < 0·001), but similar QTc. Both CD and ECG evidence of LVH predicted prolonged QTcd, but the association of CD with a prolonged QTcd was independent of other risk factors, including hypertension. Conclusions Prolonged QTcd in association with ECG evidence of LVH appears to be the specific feature of CD. This may be relevant in the choice of medical therapy for CD and for consideration of treatment of the comorbidities that are associated with hypercortisolaemia.     

Echocardiographic diagnosis of right ventricular hypertrophy: correlation with ECG and necropsy findings in 248 patients

Measurements of right ventricular wall thickness (RVWT) by echocardiography and at necropsy correlated well (r = 0.83) in 36 patients. Echocardiography had a sensitivity of 93% and a specificity of 95% in diagnosing right ventricular hypertrophy (RVH) at necropsy; electrocardiography (ECG) had a sensitivity of 31% and a specificity of 85% in diagnosing RVH. An additional 212 patients were studied by echocardiography and ECG. Based on echocardiographic criteria of RVH (RVWT Greater Than or Equal To 5 mm), 134 of 212 patients had RVH, and 78 were without RVH: the ECG had a sensitivity of 27% and a specificity of 88% for diagnosing RVH when correlated with the echocardiographic criteria. The mean diastolic RVWT was 6.0 +/- 1.4 mm in 134 RVH patients and 3.4 +/- 0.8 mm in 78 no-RVH patients (P Less Than 0.05). Diagnosis of RVH was difficult by ECG in 73 patients due to conduction defects or old myocardial infarction; the RVWT measurements were useful in evaluating RVH in these patients. We conclude that echocardiographic measurements of RVWT are useful in the diagnosis of RVH and are more sensitive than the ECG criteria in adults.     

Human immunodeficiency virus-associated pericardial effusion: report of 40 cases and review of the literature

BACKGROUND: Human immunodeficiency virus (HIV)-associated pericardial effusion is common. We present its clinical features, cause, and prognosis on the basis of a review of 40 cases at a single public hospital. METHODS: A retrospective study was conducted of 122 patients with pericardial effusion (of which 40 were HIV associated) admitted to Queens Hospital Center from January 1988 to April 1997. A review of the literature is also presented. RESULTS: Forty patients with HIV-associated pericardial effusion represent 33% of the 122 patients with pericardial effusion admitted during that period. The most common symptom of the 40 patients was dyspnea (75%). Echocardiogram detected small effusions in 18 (45%), moderate effusions in 10 (25%), and large effusions in 12 (30%). Sixteen (40%) patients had cardiac tamponade, in 15 of whom pericardiocentesis or pericardiostomy was performed. Causes of cardiac tamponade were Mycobacterium species in 3 (19%), Streptococcus pneumoniae in 1 (6%), Staphylococcus aureus in 1 (6%), Kaposi's sarcoma in 1 (6%), and unknown in 10 (63%). In comparison, causes of cardiac tamponade in 74 cases of acquired immunodeficiency syndrome in the literature were 45% idiopathic, 20% mycobacteria, 19% bacteria, 7% lymphoma, 5% Kaposi's sarcoma, 3% viruses, and 1% fungus. Thirteen of the 40 patients were lost to follow-up. Among the other 27, 11 (41%) were alive at 3 months and 5 (19%) at 1 year. Ten of the 27 patients had cardiac tamponade, of whom 5 (50%) were alive at 3 months and 3 (30%) at 1 year. CONCLUSIONS: HIV-associated pericardial effusion is the most common type of pericardial effusion in our inner city hospital. Causes are diverse. The development of pericardial effusion predicts a poor prognosis in HIV infection.     

Low electrocardiographic voltage in pericardial effusion

Although low ECG voltage has been associated with pericardial effusion, its diagnostic usefulness in such patients is unclear. When we examined the relationship between the volume of pericardial effusion and low voltage in 28 patients who underwent pericardial drainage, 14 patients exhibited low voltage (sum of limb lead QRS amplitudes of 30 mm or less). In eight patients, the QRS amplitude was 5 mm or less in each of the standard leads (absolute low voltage). There was no significant correlation between the volume of the effusion and the QRS amplitude (r = -0.30). This correlation did not improve (r = -0.37) when patients with left ventricular hypertrophy were excluded. Following pericardial drainage, the QRS amplitude increased in 21 of 24 patients and decreased in three. Low voltage persisted in nine patients; the pericardium was thickened in seven of the nine. Analysis of the sensitivity and specificity revealed acceptable sensitivity only with large effusions and no left ventricular hypertrophy. Absolute low voltage appeared to be specific in the diagnosis of moderate and large effusions among patients with pericardial effusion selected for this study.     

Clinical significance of low voltage in asymptomatic patients with pericardial effusion free of heart disease

STUDY OBJECTIVE: The purpose of this study was to evaluate the diagnostic value of low voltage with PR-segment and ST-T wave changes in determining the amount of clinically silent pericardial effusion detected in a routine echocardiography. DESIGN: Consecutive case series analysis. SETTING: Noninvasive cardiology department of a university hospital. PATIENTS: Among 8,041 consecutive patients referred to our echocardiography laboratory, 121 asymptomatic patients with pericardial effusion free of heart disease were studied. INTERVENTIONS: Echocardiography and ECG. Measurements and results: The amount (small or moderate/large) of pericardial effusion was correlated with ECG. Among 121 patients with pericardial effusion, low voltage was detected in 32 patients (26%), while widespread PR-segment depression was observed in 32 patients (26%) and widespread ST-segment elevation in 8 patients (7%). Although there was a significantly higher incidence of low voltage in patients with moderate/large pericardial effusion compared to that of small pericardial effusion, 13 of 32 patients (41%) with low voltage had a small pericardial effusion. In patients with a small pericardial effusion, 7 of 13 patients (54%) with low voltage had PR-segment depression, while 15 of 85 patients (18%) without low voltage had PR-segment depression; the difference was significant (p = 0.011). In patients with moderate/large pericardial effusions, there was no significant difference in the incidence of PR-segment depression between patients with and without low voltage (47% vs 25%, respectively; p = 0.791). CONCLUSIONS: In the presence of PR-segment depression, even a small pericardial effusion may cause low voltage in the surface ECG.