Pericardial Effusion Signals Worse Prognosis in COVID-19 Inpatients

Pericardial involvement is common in patients hospitalized with COVID-19 and, when combined with a focused clinical and echocardiographic evaluation, may help identify those at higher risk for mortality, a prospective study shows.

Overall, 14.2% of patients had pericardial effusion, mostly classified as mild, although only 17 patients (3.2%) met criteria for acute pericarditis, according to a study published last week in the Journal of the American Heart Association.

Pericardial effusion was not significantly associated with mortality after taking into account an extensive set of clinical, echocardiographic, and hemodynamic parameters (HR 1.96; 95% CI 0.89-4.09).

Such a comprehensive evaluation might not be possible when a hospital is being strained by an influx of COVID-19 cases, however, and when considered among a more-limited, easier-to-obtain set of clinical and echo parameters, the presence of pericardial effusion was independently associated with mortality (HR, 1.86; 95% CI 1.09-3.07).

“Adding pericardial effusion to the limited echo assessment of COVID patients can add a lot to the prognostic evaluation,” said Eihab Ghantous, MD (Tel Aviv Sourasky Medical Center, Israel), who is scheduled to present the findings as a poster at the American College of Cardiology 2022 Scientific Session starting later this week. He told TCTMD that in this scenario, pericardial involvement should indicate to physicians that the patient will have a more-difficult clinical course and should receive additional attention.

COVID-19 now has a wide-ranging and well-established impact on the cardiovascular system and this research group previously showed that the most-common cardiac manifestations in a hospitalized cohort were RV dysfunction and dilatation, followed by LV diastolic and systolic dysfunction. But most prior studies have focused on myocardial involvement, with scarce data on pericardial disease.

Ghantous et al help fill this gap with a study of patients who underwent evaluation at their center using a prospectively defined protocol, which “included clinical symptoms and signs suggestive of pericarditis, calculation of modified early warning score [MEWS], ECG and echocardiographic assessment for pericardial effusion, left and right ventricular systolic and diastolic function, and hemodynamics.”

Adding pericardial effusion to the limited echo assessment of COVID patients can add a lot to the prognostic evaluation. Eihab Ghantous

All 530 patients (mean age 63.1 years; 62% men) included in the analysis were admitted between March 21 and September 16, 2020, and underwent transthoracic echo within 48 hours. Roughly half (52%) had mild/moderate COVID-19 (oxygen saturation ≥ 94% in room air), 44% had severe disease (a need for oxygen supplementation), and 4% had critical disease (a need for mechanical ventilation or use of vasopressors and/or extracorporeal membrane oxygenation).

Pericardial effusion, found in 75 patients, was independently associated with a worse MEWS (which itself has been associated with a need for mechanical ventilation and mortality in COVID-19 patients), a higher level of brain natriuretic peptide, and poorer RV function.

Overall, the mortality rate was higher in patients with versus without pericardial effusion (33.3% vs 15.8%), although the difference remained significant only when adjustment wasn’t made for the full set of clinical, echo, and hemodynamic parameters. For instance, when combined with the MEWS along with LVEF and tricuspid annular plane systolic excursion on echo (without Doppler hemodynamic parameters), pericardial effusion was independently associated with mortality.

“In the present work, we demonstrate that once comprehensive noninvasive hemodynamic evaluation is performed, pericardial effusion has only marginal additive value for predicting mortality,” the investigators say. “However, once limited echocardiography is performed, simple evaluation for the presence of pericardial effusion has significant additive predictive value in hospitalized patients.”

This simpler evaluation could be useful, Ghantous said, when there isn’t time to get all of the echo parameters that can be obtained—during a COVID-19 surge, for instance. In this situation, “you see that the addition of pericardial effusions adds a lot to the prognostic value.”

I don’t think the presence of a pericardial effusion is going to necessarily make or break our understanding or our assessment of a COVID-19 patient. Donald Lloyd-Jones

Commenting for TCTMD, Donald Lloyd-Jones, MD (Northwestern Medicine, Chicago, IL), president of the American Heart Association, said that even though the study didn’t capture all hospitalized patients with COVID-19, it did a good job at capturing as many as possible, rather than only including patients who were referred for echocardiography for a specific reason.

It’s not surprising, he said, that pericardial effusion was a common finding, since it’s frequently seen in patients with pneumonia and systemic illnesses that cause inflammation in the chest. Nonetheless, the study provides “nice documentation that people shouldn’t be surprised if they see this finding and that, in and of itself, it doesn’t seem to lead to any complications but it does seem to be a marker of a sicker patient.”

As for the risk-stratification approach suggested by the investigators—combining a limited echo evaluation with the presence of pericardial effusion—Lloyd-Jones didn’t see a major clinical role.

“It’s going to be pretty obvious clinically the patients that are sick. I don’t think the presence of a pericardial effusion is going to necessarily make or break our understanding or our assessment of a COVID-19 patient,” he said. “It could be a tool that people would use. I don’t think it’s likely to be one of the things that we’ll do routinely, . . . because there are many other things that we are using to assess the severity of COVID illness and the likelihood of progression to a complication.”

Still, studies like this are useful, Lloyd-Jones indicated. “We’re still learning so much about this illness and the course of it, and so it is important to keep up this research so that we understand just what’s critically important and what the time course and complicating factors can be from this systemic illness,” he said. “We certainly want to continue to support people that are doing this research and finding new things for clinicians to take into consideration when they’re caring for COVID patients.”