A 65-year-old woman comes to the physician because of generalized weakness, weight gain, and leg swelling for the last several weeks. Her appetite is decreased. She denies shortness of breath, chest pain, or cough. Her other medical problems include hypertension and type 2 diabetes mellitus. She had positive skin tuberculin skin test approximately 20 years ago when she moved to the United States from India, and she received 9 months of isoniazid therapy. Her medications include ramipril and atenolol. Her temperature is 36.1 C (97 F), blood pressure is 150/100 mm Hg, and pulse is 60/min. Her BMI is 30 kg/m². Examination shows normal jugular venous pressure and muffled first and second heart sounds. Her lungs are clear to auscultation. There is no hepatomegaly or splenomegaly. Examination shows 1+ pitting edema to the mid-shin bilaterally. Laboratory results are as follows: Electrocardiogram shows low voltage complexes and sinus bradycardia. Echocardiogram reveals normal left ventricular size, a left ventricular ejection fraction of 50%, and a mild-to-moderate pericardial effusion. There is no right atrial or right ventricular collapse. Which of the following is the most appropriate next step in management?

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11ec193a_97a4_f311_853d_55b26ac4913f_MD0002_00 Significant hypothyroidism can cause a pericardial effusion, but the clinical features are usually nonspecific for hypothyroidism and require a high index of suspicion for diagnosis. This patient has a moderate pericardial effusion without features of cardiac tamponade (e.g., right ventricular collapse), suggesting that the effusion developed slowly. Pericardial effusion is commonly caused by infections (e.g., viral, bacterial, fungal, and tuberculosis), uremia, hypothyroidism, collagen vascular disease, malignancy, post-myocardial infarction, and trauma. Initial work-up of patients with chronic pericardial effusion includes a complete blood count, basic metabolic panel, thyroid function tests, anti-double stranded DNA antibodies, and complement levels. This patient most likely has hypothyroidism, and the pericardial effusion typically responds to levothyroxine therapy. Patients with untreated hypothyroidism are at a higher risk of coronary artery events. (Choice A) A CT scan and MR imaging are indicated for a loculated effusion, suspected pericardial thickening (which can be missed on echocardiography), and differentiating constrictive pericarditis from restrictive cardiomyopathy. This patient had a positive tuberculin skin test in the past treated with isoniazid; she does not need repeat testing. (Choice B) Loop diuretics and ACE inhibitors will lead to symptomatic improvement in congestive heart failure, but the normal jugular venous pressure and liver size makes this less likely. Pitting edema is most likely due to hypothyroidism. (Choice C) Pericardiocentesis is required for significant tamponade, suspicion of infectious (purulent or tuberculous) or malignant pericarditis, or for effusions not responding quickly to medical therapy. This patient has a mild-to-moderate effusion without tamponade and does not need immediate pericardiocentesis. (Choice D) Right ventricular catheterization is most useful for differentiating constrictive pericarditis from restrictive cardiomyopathy, which is less likely in this patient given the normal jugular venous pressure and liver size. Educational objective: Initial work-up of patients with chronic pericardial effusion includes a complete blood count, basic metabolic panel, thyroid function tests, anti-double stranded DNA antibodies, and complement levels. __________ References: Link between pericardial effusion and attenuation of QRS voltage in patients with hypothyroidism. (http://www.ncbi.nlm.nih.gov/pubmed/20424451) Pericardial effusion in primary hypothyroidism. (http://www.ncbi.nlm.nih.gov/pubmed/2248183) Pericardial effusion associated with subclinical hypothyroidism. (http://www.ncbi.nlm.nih.gov/pubmed/19376599)

A 65-Year-Old Woman Comes to the Physician Because of Generalized