Constrictive Pericarditis

Related Subjects: |Assessing Breathlessness |Assessing Chest Pain |Pericardial Effusion and Tamponade |Constrictive Pericarditis |Colchicine |Chest X Ray Interpretation

📖 About

• Constrictive pericarditis = rigid pericardium → heart trapped in a “small rigid box.”
• ❌ Restricts normal diastolic filling → impaired cardiac output.
• JVP: prominent x descent; y descent prominent (lost in tamponade).
• Key haemodynamics: dip & plateau / “square root sign” on pressure tracings.

🦠 Causes

• Idiopathic / Post-viral 🌐 → most common in developed countries.
• Tuberculosis 🦠 → commonest cause worldwide, esp. developing countries.
• Post-surgical or Post-radiation 🏥 → scarring after cardiac surgery or mediastinal radiotherapy.
• Inflammatory / Autoimmune 🤲 → RA, SLE, systemic autoimmune disease.
• Metabolic 💉 → Uraemia, trauma.
• Malignancy 🎗️ → primary pericardial tumours or secondary invasion.
• Drugs 💊 → hydralazine, procainamide, methysergide.

🧬 Pathophysiology

• Ventricular filling impaired in mid/late diastole.
• All diastolic pressures equalise (RA, RV, LA, LV).
• Dip and plateau waveform = rapid early filling then abrupt halt ⏹.

🩺 Clinical Features

• 📉 Symptoms: fatigue, weakness, ascites, breathlessness, orthopnoea.
• 🫀 Signs:
  • Soft heart sounds, impalpable apex beat.
  • Signs of right heart failure: hepatomegaly, ascites, pleural effusion.
  • Raised JVP with both x & y descents (Friedreich’s sign).
  • Kussmaul’s sign → JVP rises with inspiration (normally falls).
  • Pericardial knock → early diastolic sound (mimics S3).
  • Pulsus paradoxus (more classic in tamponade, but can occur here).
• ❌ Pulmonary oedema suggests another diagnosis (think restrictive cardiomyopathy).

🔎 Investigations

• 🧪 Bloods: FBC, U&E, CRP → look for TB, uraemia, inflammation.
• 📷 CXR: pericardial calcification, pleural effusions.
• 📉 ECG: low QRS voltage, widespread T wave flattening/inversion, P mitrale.
• 🩻 Echo: thickened, bright pericardium ± septal bounce.
• 🧭 Cardiac catheterisation: square root sign (early dip + plateau).
• 🧲 CT / MRI: confirm thickened or calcified pericardium, assess extent.
• 🔬 Pericardial biopsy if unclear (TB, malignancy).

🛠️ Management

• Medical 💊:
  • Diuretics → relieve fluid overload (symptomatic only).
  • NSAIDs or steroids if active inflammation present.
• Surgical 🔪:
  • Pericardiectomy = definitive treatment.
  • High-risk surgery but often curative in severe symptomatic cases.

📚 References

• ESC Guidelines – Pericardial Diseases (2015)

Cases — Constrictive Pericarditis

• Case 1 — Post-Tuberculosis Pericarditis: A 45-year-old man from South Asia presents with progressive breathlessness, abdominal distension, and leg swelling. On exam: raised JVP with prominent y descent, hepatomegaly, ascites, and peripheral oedema. Heart sounds are quiet, and a pericardial knock is heard in early diastole. CXR: pericardial calcification. Echocardiography: septal bounce and ventricular interdependence. Diagnosis: Constrictive pericarditis secondary to TB infection. Management: Optimise with diuretics for fluid overload; definitive treatment is pericardiectomy in suitable patients.
• Case 2 — Post-Cardiac Surgery Patient: A 62-year-old woman presents 1 year after CABG surgery with exertional dyspnoea, fatigue, and ankle oedema. Examination: raised JVP with Kussmaul’s sign, hepatomegaly, ascites. ECG shows low-voltage QRS. Echocardiography: thickened pericardium with abnormal ventricular filling. Cardiac catheterisation: equalisation of diastolic pressures in all four chambers. Diagnosis: Constrictive pericarditis post-cardiac surgery. Management: Symptomatic relief with diuretics initially; surgical pericardiectomy is the only curative therapy.

Teaching Commentary ❤️

Constrictive pericarditis occurs when the pericardium becomes fibrosed and rigid, impairing diastolic filling and mimicking right heart failure. Causes include tuberculosis, previous cardiac surgery, radiation, and idiopathic/viral. Classic findings: raised JVP with rapid y descent, Kussmaul’s sign, ascites, hepatomegaly, peripheral oedema, and a pericardial knock. Echo and CT/MRI can confirm thickened, calcified pericardium. Management is mainly supportive with diuretics, but definitive treatment is pericardiectomy in patients with severe, persistent symptoms.