Chest

Chest

Volume 111, Issue 5, May 1997, Pages 1213-1221
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Clinical Investigations: Cardiology
The Usefulness of Diagnostic Tests on Pericardial Fluid

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Study objectives

To determine the physical, chemical, and cellular characteristics of pericardial fluid in various disease states and to assess their diagnostic accuracies.

Setting

A metropolitan university hospital.

Patients

One hundred seventy-five hospital patients, aged 1 month to 87 years, who had undergone pericardiocentesis (n=165) or control subjects who had undergone open heart surgery (n=10) between 1984 and 1996.

Measurements

The appearance of pericardial fluid and results of chemistry tests, cell counts, cytologic studies, Gram’s stain, and microbial cultures were obtained by chart review. The etiology of each pericardial fluid sample was determined using prospective diagnostic criteria.

Results

Exudates differed from transudates by higher leukocyte counts and ratios of fluid to serum lactate dehydrogenase levels. Fluid glucose levels were significantly less in exudates. Sensitivity for detecting exudates was high for specific gravity >1.015 (90%), fluid total protein >3.0 g/dL (97%), fluid to serum protein ratio >0.5 (96%), fluid lactate dehydrogenase ratio >0.6 (94%), and fluid to serum glucose ratio <1.0 (85%). None of these indicators were specific. Fluid total protein and specific gravity were moderately correlated (r=0.56). Fluid cytologic study had a sensitivity of 92% and specificity of 100% for malignant effusion. No other test was diagnostic for a specific etiology. Among infection-associated effusions, culture-positive fluid had more neutrophils, higher lactate dehydrogenase levels, and lower ratios of fluid to serum glucose than culture-negative (parainfective) fluid.

Conclusions

Evaluation of pericardial fluid might be limited to cell count, glucose, protein, and lactate dehydrogenase determinations plus bacterial culture and cytology. While not used routinely, other tests that may be highly specific for particular diseases should be ordered only to confirm a high clinical suspicion.

Section snippets

MATERIALS AND METHODS

The charts of patients admitted to Kansas University Medical Center who underwent pericardiocentesis between January 1, 1984 and January 30, 1992 were identified by a computer search of medical records for pericardiocentesis (International Classification of Diseases code 37.0). One hundred sixty-seven cases were identified. Two were excluded because no laboratory studies had been obtained.

Each hospital discharge summary was reviewed for the cause of the pericardial effusion as originally

RESULTS

The results from 82 male and 93 female subjects aged 46.0±21.6 years (range, 1 month to 87 years) are included. Exudative effusions included those diagnosed as malignant (n=37), viral (n=19), bacterial (n=9) or associated with infection but with no growth on cultures (parainfective) (n=6), rheumatologic (n=8), or postpericardiotomy (n=8) based on the degree of inflammation inherent in each disease process.3, 4, 5 Transudates included those effusions due to radiation (n = 15), uremia (n=15),

DISCUSSION

We are unaware of any other studies that have systematically evaluated the usefulness of laboratory tests performed on pericardial fluid. In the era of outcomes analysis, such critical evaluation is important. Since a battery of tests including microbial cultures, cytology, and chemical tests were obtained almost routinely, selection bias is minimal. The clinical diagnosis was generally not confirmed histologically, thus allowing some risk of misclassification of diagnoses.

To our knowledge, no

CONCLUSIONS

Diagnostic evaluation of pericardial fluid should begin with differentiation between exudate and transudate. The identification of an exudate is best done with one or more of four tests using the following cut points: fluid total protein level >3.0 g/dL; fluid to serum total protein ratio >0.5; fluid to serum lactate dehydrogenase ratio >0.60; and fluid lactate dehydrogenase <300 U/dL.

Two other tests should also be ordered routinely based on their high specificity and the crucial importance of

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    Copyright © 1997 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.