Table of Contents
- Definition of Constructive Pericarditis
- Epidemiology of Constructive Pericarditis
- Etiology of Constructive Pericarditis
- Pathology and Pathophysiology of Constructive Pericarditis
- Symptoms of Constructive Pericarditis
- Diagnosis of Constructive Pericarditis
- Differential Diagnoses of Constructive Pericarditis
- Therapy of Constructive Pericarditis
- Progression and Prognosis of Constructive Pericarditis
- Review Questions
Definition of Constructive Pericarditis
Constrictive pericarditis limits the heart’s ability to function normally due to a thickened and scarred pericardial sac which lays around the heart. This prevents proper diastolic filling.
Epidemiology of Constructive Pericarditis
Spread of constrictive pericarditis
Constrictive pericarditis is much less common compared to acute pericarditis. Approximately 10 % of acute pericarditis progress to constrictive pericarditis. Middle age males are the most predominant group.
Etiology of Constructive Pericarditis
Causes of constrictive pericarditis
In the past, constrictive pericarditis was associated with bacterial pericarditis and purulent pericarditis. In the developed world this is a rare finding. Constrictive pericarditis is often iatrogenic following open heart surgery or radiation therapy for the treatment of mastocarcinoma and other cancers. Radiation induced constrictive pericarditis usually presents 10 years after therapy. In the developing world tuberculosis is a common cause of constrictive pericarditis.
Pathology and Pathophysiology of Constructive Pericarditis
Inflammation of the pericardial sac results in the release of fibrin and the formation of effusion. If this results in organization the parietal and visceral linings will become thickened and fuse. This sclerotic pericardium cannot expand and will prevent the heart from filling during diastole, resulting in a right sided heart failure.
Symptoms of Constructive Pericarditis
Signs of constrictive pericarditis
Constrictive Pericarditis results in a right sided heart failure. Symptoms include:
- Edema of the extremities
- Swollen abdomen: hepatomegaly, ascites
- Hepatic congestion: right upper quadrant pain of the abdomen
- Other symptoms include: fatigue, chest pain, palpitations
On physical exam, a pericardial knock may be heard at the left sternal border in early diastole. Hepatomegaly and hepatic pulsations are also findings of constrictive pericarditis.
Diagnosis of Constructive Pericarditis
ECG findings are usually nonspecific and include a low voltage QRS complex in all leads and T wave inversions. Kussmaul’s sign, a rise in jugular venous pressure with inspiration (normally it should drop with inspiration) is a nonspecific finding and is found in restrictive pericarditis, restrictive cardiomyopathy, and tricuspid stenosis.
Echocardiography is the preferred method to diagnose constrictive pericarditis. Abnormalities of chamber filling and pericardial distortions will be visible. Chest X-ray may show pericardial calcification or pleural effusions. Cardiac catheterization can identify abnormal cardiac filling pressure, another sign of constrictive pericarditis. It is invasive and not a first line diagnostic procedure.
Differential Diagnoses of Constructive Pericarditis
- Acute pericarditis
- Atrial myxoma
- Cardiac tamponade
- Cirrhosis of the liver
- Dilated cardiomyopathy
- Myocardial infarction
- Pericardial effusion
- Restrictive cardiomyopathy
Therapy of Constructive Pericarditis
Treatment of constrictive pericarditis
Medical management is usually ineffective. However, diuretics are helpful early in the disease. Definitive treatment is pericardiectomy or pericardial stripping. This procedures has significant risk associated with it. In pericardiectomy, some or most of the pericardium is surgically removed.
Progression and Prognosis of Constructive Pericarditis
The best strategy in treating constrictive pericarditis is to recognize it and start treatment as early as possible. Constrictive pericarditis responds poorly to medical intervention, while surgical treatment is the definitive but risky. Long term prognosis depends on etiology. Idiopathic constrictive pericarditis has the best prognosis, followed by post-surgery constriction. Post radiation constriction has the worst prognosis.
The solutions are located below the sources.
1. Which of the following is not a symptom of constrictive pericarditis?
- Extremity edema
- Chest pain
2. Kussmaul’s sign is caused by which condition?
- Constrictive pericarditis
- Tricuspid stenosis
- Restrictive cardiomyopathy
- All of the above