İnvestigation of pericardial effusion frequency by ultrasonography in malignant patients presenting to emergency department

Aim: Cancer; is one of the common diseases that cause death most after heart disease, which greatly reduces the quality of life and life expectancy. It is known that as the diagnosis and treatment methods develop, the incidence of the malignancy and the life expectancy increase. Pericardial effusion is a complication seen in many types of malignancies, mainly Lung cancer and Breast cancer. In our study, we investigated the frequency of pericardial effusion diagnosis by ultrasonography in malignant patients who applied to our emergency department with any complaint. Patients and method: Bülent Ecevit University Medical Faculty Hospital Emergency Department has been prospectively examined for patients diagnosed or newly diagnosed, over the age of 18, non trauma cancer patients and who applied between March 20 and September 20, 2016. Clinical and demographic characteristics of the patients were evaluated. In our study age, gender, applicant complaints, comorbid diseases, vitals, diagnosis after emergency care, type of diagnosed malignancy, how many months they had the malignancy, metastases and the treatments that they had received were evaluated. Pericardial effusion was evaluated with bedside ultrasonography applied by ultrasound-trained research assistants and lecturers in our clinic. According to measurable quantity, pericardial effusions were classified into three groups as 5-10 mm mild, 11-20 mm moderate and higher than 20 mm large. Data saved and statistical analyses has made via using SPSS 17.0 for Windows. And value of p<0.05 were accepted statistically significant. Findings: 227 patients were included in the study. 69.2% (n = 157) of the patients were male and 30.8% (n = 70) of the patients were female. The mean age of males was 66.9 ± 10.2, and the mean age of females was 62.2 ± 12.6. Complaints about the gastrointestinal system (25,1%) and respiratory complaints (22,9%) were in the forefront when the complaints of the Emergency Service were evaluated. According to their diagnoses, gastrointestinal system (20.3%), respiratory system (19.8%), infection (14.1%) and cardiovascular system (13.2%) were the most commonly diagnosed. Comorbid disease was detected in 69.6% of the patients (n = 158). Hypertension (HT), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD) were the most common diseases in terms of co-morbid diseases. Malignancy type (28.2%) lung cancer, (14.1%) colon cancer and (7.9%) breast cancer were more frequent. The median time since diagnosis of malignancy was 12 months (range 1 to 25 years). 55.5% (n = 126) of metastases were detected in the patients. Bone metastasis (30.4%), liver metastasis (%17.2), lung metastasis (10.6%) were more frequent. The mild (5-10mm) effusion was found to be 33.5% (n = 76) 'inde, moderate (11-20mm) effusion 11,5% (n = 26)' in patients. Lung cancer was found in 18, Breast cancer in 9, and Colon cancer in 8 of 76 (33.5%) patients with mild effusion. Lung cancer was found in 9 of 26 (11.5) patients with moderate effusion, Colon cancer in 5, and Bladder-kidney cancer in 4. 3 patients(1.3%) with large effusion had lung cancer in 2 and bladder cancer in one. There was no relationship between the presence of metastases and effusion (p = 0.541). There was no relationship between chemotherapy intake status and effusion presence (p = 0.527). There was no correlation between radiotherapy intake status and effusion presence (p = 0.239). Efficacy was more common in patients with co-morbid disease (p = 0.022); Also effusion was more frequent in coronary artery disease CAD cases (0.007). There was a weak correlation between the systolic blood pressure and the amount of effusion in the negative direction (p = 0.037, r = -0.138). ECG findings detected in three patients with large effusion were atrial fibrillation and normal ECG. Atrial fibrillation was the most common pathologic ECG finding in all patients with less or greater effusion. In patients with pleural effusion, cardiac effusion was seen in 64.1% of the patients, whereas in patients without pleural effusion, this rate was 42.6%. Cardiac effusion was more common in patients with pleural effusion (p = 0.014). Cardiac effusion was seen in 68.6% of patients with cardiothoracic ratio (CTR) increase, whereas this rate was 42.2% without CTR increase. Cardiac effusion was more frequent in patients with CTR increase (p = 0.004). Result: The most common cause of malignant pericardial effusion is lung cancer. As might be expected, the most common malignancy responsible for pericardial effusion was lung cancer (%28,2) in our study. The most common electrocardiographic (ECG) findings are sinus tachycardia, low QRS voltage and electrical alternans in patients with pericardial effusion. Electrical alternans is highly spesific but not sensitive finding. In our study, patients with large effusions had atrial fibrillation and normal ECG findings. Unexpectedly though, the most common ECG finding was atrial fibrillation in patients with mild and moderate effusion. In many studies, pericardial effusion induced by chemoradiotherapy has been reported. However, there was neither chemotherapy induced nor radiotherapy induced association with pericardial effusion in our study. This study demonstrates the importance of using bedside ultrasonography as an accessible, fast and time-saving method in malignant pericardial effusion which could become a life-threatening disease. Bedside cardiac ultrasonography in emergency departments should be supported and its usage should be as common as a stethoscope.