Constrictive Pericarditis

Question 1

Define constrictive pericarditis.

Answer 1

Chronic inflammation of the pericardium with thickening and scarring.

Question 2

How common is constrictive pericarditis?

Answer 2

Incidence is decreasing as with many conditions that have an infectious component

Question 3

Summarise the pathophysiology of constrictive pericarditis.

Answer 3

The pericardium is the sac that encloses the heart. It becomes inflamed in constrictive pericarditis.

There are 2 layers of pericardium (visceral and parietal). These 2 layers are normally distensible with a small space between them containing fluid. However, in constrictive pericarditis they become inflamed and they fuse.

Basically it acts as if there was a box around the heart.

Question 4

What are the most common causes of constrictive pericarditis?

Answer 4

ANY CAUSE OF PERICARDITIS ESPECIALLY TB

• 90% idiopathic or viral e.g., Coxsackie virus A9 or B1-4, Echo 8, mumps, EBV, cytomegalovirus, varicella, rubella, HIV, Parvo-19
• TB, bacterial (include staph and pseudomonas)

Other causes:

• Cardiac surgery and radiation
• Incomplete drainage of purulent pericarditis
• Post-MI
• In association with pulmonary asbestos

Question 5

What are the clinical features of constrictive pericarditis?

Answer 5

• RHF symptoms (dyspnoea, ↑ JVP, fluid congestion, ascites, hepatomegaly, oedema)
• Kussmaul’s sign positive
• JVP has prominent X and Y descent
• Pericardial knock - loud S3
• Fatigue

Question 6

What investigations would you do for constrictive pericarditis?

Answer 6

Investigations:

• CXR: pericardial calcification
• ECHO: ↑ pericardial thickness - helps distinguish restrictive cardiomyopathy
• Cardiac CT/MRI - done before surgical management.

Question 7

What is the main differential for constrictive pericarditis?

Answer 7

Restrictive cardiomyopathy

Other pericardial compressive syndromes = cardiac tamponade, effusion-constrictive pericarditis.

Question 8

What is seen on echo in constrictive pericarditis?

Answer 8

• Increased pericardial thickness
• Abnormal septal ‘bounce’
• Ventricular and valve flow abnormalities
• Bi-atrial enlargement
• Dilated inferior vena cava and hepatic veins

Question 9

What is the management of constrictive pericarditis?

Answer 9

Early disease - MEDICAL → NSAIDs + colchicine trial for 2-3months then reassess; corticosteroids/immune modulation for 2-3 months then reassess.

Late disease i.e. calcification, AF, cachexia - SURGICAL - refer to cardiothoracics for pericardiectomy [or medical e.g. diuretics if not suitable candidates for surgery]

Question 10

What are the complications of constrictive pericarditis and its management?

Answer 10

• Anasarca (swelling of whole body)
• AF
• Hepatic dysfunction
• Pleural effusion
• Ascites
• Pericardiectomy has 4-8% mortality

Question 11

What is Kussmaul’s sign?

Answer 11

JVP rising on inspiration - this occurs in constrictive pericarditis

Question 12

What are the differences between cardiac tamponade and constrictive pericarditis on examination?

Answer 12

Question 13

Define pulsus paradoxus.

Answer 13

an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg.