Thanks to Phuong today for presenting the case of a young woman who presented with volume overload, found to have constrictive pericarditis!

Clinical Pearls

• Constrictive pericarditis and restrictive cardiomyopathy can have similar clinical presentations.  Cardiac cath is generally needed to help distinguish between the two.
• The most common cause of constrictive pericarditis is idiopathic!
• Exam findings in constrictive pericarditis include volume overload, pulsus paradoxus, Kussmaul’s sign, pericardial knock, and occasionally (<20% of the time) pericardial friction rub.
• ECG and CXR can be normal in constrictive pericarditis.
• Treatment of early disease is supportive care.  Treatment of late stage constrictive pericarditis is pericardiectomy.

Etiologies of constrictive pericarditis:

• Idiopathic (42-61%) ⇒ most common cause!
• Post-cardiac surgery (11-37%)
• Post-radiation therapy (2-31%) particularly after Hodgkin disease or breast cancer
• Connective tissue disorder (3-7%)
• Post-infectious – TB or purulent pericarditis (3-15%)
• Miscellaneous causes (malignancy, trauma, drug-induced, asbestosis, sarcoidosis, uremic pericarditis) (1-10%)

Clinical Presentation

• Symptoms related to fluid overload
• Symptoms related to diminished cardiac output in response to exertion
• Exam:
  • Elevated JVP
  • Pulsus paradoxus – drop in SBP >10 mmHg due to drop in stroke volume and cardiac output with inspiration (20%)
  • Kussmaul’s sign – lack of an inspiratory decline in JVP.  (Also present in people with severe tricuspid valve disease or R heart failure.
  • Pericardial knock – 47%
  • Pericardial friction rub – 16%
  • Stigmata of heart failure
• ECG: can be normal
• CXR: Majority of people do NOT have pericardial calcifications
  • Interestingly, calcifications are more common in people with idiopathic disease, a longer duration of symptoms, and those with TB!

Management of Constrictive Pericarditis

• Early disease is usually managed with supportive care.  Diuretics can help mitigate symptoms of volume overload but must be used cautiously due to preload dependent physiology.
• Late stage disease is treated with pericardiectomy.  Complication rates tend to be high and operative mortality can reach 12%!

Constrictive Pericarditis vs Restrictive Cardiomyopathy:

We also talked about a helpful way of breaking up new onset ascites to help generate a DDx: