Pericardial Effusion in Adults: a systematic review of epidemiology, etiologies, diagnosis, and management – ​​updated 2025

Abstract

Introduction: Pericardial effusion (PE) is defined as an abnormal accumulation of fluid in the pericardial space and encompasses a wide spectrum of etiologies, ranging from benign conditions to life-threatening causes such as cardiac tamponade. Advances in imaging, image-guided interventions and understanding of the underlying pathophysiology justify an updated synthesis of the literature. Objective: To systematically review contemporary evidence on the epidemiology, etiologies, imaging-based diagnosis and therapeutic management of pericardial effusion in adults, focusing on studies published between 2000 and 2025. Methods: A systematic search was conducted in PubMed/MEDLINE, Embase, Cochrane Library and Google Scholar. Eligible studies included cohort and observational studies, clinical series with ≥20 patients, systematic reviews and guidelines. Pre-clinical, pediatric-only, very small series and purely narrative reviews were excluded. Two independent reviewers screened and selected the studies according to PRISMA principles. Extracted data included epidemiology, causes, diagnostic methods, echocardiographic parameters, management strategies (pericardiocentesis, surgery, adjuvant therapies), prognosis and recurrence. Results: A total of 3,274 records were identified, of which 82 met inclusion criteria. The most frequent etiologies were idiopathic/viral (20–30%), neoplastic (10–25%), post-operative (15–20%), uremic (5–15%), tuberculosis (in endemic regions: up to 70% of severe cases), autoimmune diseases (5–10%) and hypothyroidism (up to 5%). Transthoracic echocardiography remains the main diagnostic tool, while tomography and cardiac magnetic resonance are useful in complex or loculated effusions. Management is driven by effusion volume, rate of accumulation and hemodynamic impact. Image-guided pericardiocentesis shows a success rate of 92–98% with low procedure-related mortality (<1%), whereas malignant effusions present higher recurrence rates (up to 40%). Surgical pericardial window is associated with lower recurrence at the cost of greater invasiveness. Conclusion: Pericardial effusion is a multifactorial condition requiring rapid and structured evaluation. Echocardiography is the cornerstone of diagnosis, and image-guided pericardiocentesis remains the first-line intervention in symptomatic or hemodynamically unstable effusions. Ongoing advances in imaging, biomarkers and minimally invasive therapies continue to improve outcomes.