Thanks to Phuong today for presenting the case of a young woman who presented with volume overload, found to have constrictive pericarditis!
- 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%)
- Symptoms related to fluid overload
- Symptoms related to diminished cardiac output in response to exertion
- 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: