Constrictive Pericarditis Symptoms and Treatment Guidelines

Can you die from constrictive pericarditis? How to differentiate restrictive cardiomyopathy from constrictive pericarditis? But, first, let’s find out about constrictive pericarditis symptoms and treatment!

Constrictive Pericarditis Definition

Constrictive pericarditis meaning – What is constrictive pericarditis? Constrictive pericarditis is a diastolic heart failure caused by a stiff pericardium that makes it hard for the heart to fill with blood.

constrictive pericarditis symptoms and treatment guidelines - constrictive pericarditis radiology

Constrictive Pericarditis Causes

What causes constrictive pericarditis? What is the most common cause of constrictive pericarditis?

Pericardial inflammation can lead to a thickened, fibrotic, and stuck-together pericardium. This makes it hard for the heart to fill during diastole and keeps the pressure in the veins high for a long time. In the past, tuberculosis was the most common cause of constrictive pericarditis. This is still true in developing countries, but not the rest of the world.

After recurrent pericarditis, constrictive pericarditis doesn’t happen very often. Less than 1% of people with viral or idiopathic pericarditis will develop constrictive pericarditis. It happens more often after immune-mediated or neoplastic pericarditis (2–5%), and after purulent bacterial pericarditis (20–30%), it happens the most. Other causes are heart surgery, radiation therapy, and diseases of the connective tissues.

Some cases are caused by drugs or result from trauma, asbestosis, sarcoidosis, or uremia. Some people have both pericardial tamponade and constrictive pericarditis at the same time. This is called effusive-constrictive pericarditis. The only way to know what’s wrong is to drain the pericardial fluid and look at the underlying constrictive physiology.

To tell the difference between constrictive pericarditis and restrictive cardiomyopathy, the heart may need to be catheterized, and all noninvasive imaging methods may need to be used.

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Constrictive Pericarditis Diagnosis

Constrictive Pericarditis Symptoms

Signs and symptoms of constrictive pericarditis – What are some symptoms of constrictive pericarditis?

The main signs are shortness of breath that gets worse over time, tiredness, and weakness. Most people with this condition have chronic edema, hepatic congestion, and ascites. Ascites often seem too big for how much peripheral edema there is. The exam shows these symptoms and a typical high jugular venous pressure with a quick drop in the y. This can be found at the bedside by carefully watching the jugular pulse and looking for a pulse wave that looks bigger at the end of the ventricular systole (due to the relative accentuation of the v wave by the rapid y descent). A common finding is that the JVP doesn’t fall with the Kussmaul sign. With systole and pericardial effusion, the apex may move back. Early in diastole, you might hear a knock. Pulsus paradoxus is unusual. Most people have atrial fibrillation.

Constrictive pericarditis diagnostic test

Sometimes it’s hard to tell the difference between constrictive pericarditis and restrictive cardiomyopathy, which can happen simultaneously. When the difference isn’t clear, noninvasive tests and cardiac catheterization are used to figure it out.

Radiographic findings

The chest x-ray may show that the heart is the right size or too big. Calcification of the pericardium is rare and is best seen from the side. It rarely affects the top of the LV, and calcification at the top of the LV is more likely to be caused by an LV aneurysm.

Echocardiography

A thickened pericardium is hard to see on an echocardiogram. But it is common for the septum to “bounce,” which shows how quickly the uterus is filling. RV/LV interaction can be seen when the mitral inflow Doppler pattern drops by more than 25% during inspiration, as it does in tamponade. Most of the time, the first flow of blood from the mitral valve into the left ventricle (LV) happens very quickly. This is also shown by the Doppler inflow (E wave) pattern. Other echocardiographic features, like the medial and lateral mitral annular motion (e velocity) ratio, the respiration-related septal shift, and the hepatic vein expiratory diastolic reversal ratio, also point to constrictive physiology.

Cardiac CT and MRI

Only sometimes are these imaging tests useful. Pericardial thickening of more than 4 mm must be present to make the diagnosis, but 20–25% of people with constrictive pericarditis don’t have any thickening of the pericardium. Some MRI techniques show the septal bounce and can give more proof that the ventricles talk to each other.

Cardiac catheterization

This procedure is often used to confirm something or to find out what’s wrong when the echocardiogram results are unclear or mixed. In constriction, the pulmonary pressure is usually low (as opposed to restrictive cardiomyopathy). Because of the need to show how the RV and LV interact in constrictive pericarditis, cardiac catheterization should measure both the LV and RV pressure tracings simultaneously during inspiration and expiration. MRI of the heart can show how this interaction works.

Hemodynamically, patients with constriction have equalization of end-diastolic pressures in all of their cardiac chambers, rapid early filling, and a sudden rise in diastolic pressure “square-root sign); the RV end-diastolic pressure is more than one-third of the systolic pressure, simultaneous measurements of RV and LV systolic pressure show a discordance with inspiration (the RV rises as the IV falls), and there is usually a Kussmaul sign (failure of the RA pressure to fall with inspiration). In restrictive cardiomyopathy, the RV and LV systolic pressures are the same when you breathe in.

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Constrictive Pericarditis Treatment and Management Guidelines

Treatment of constrictive pericarditis – What is the best treatment for constrictive pericarditis?

First, therapy should be aimed at the specific cause. For example, anti-inflammatory drugs may be useful if lab tests show that inflammation is still going on. Then, once the blood flow is clear, diuresis is the mainstay of treatment. As with other types of right heart failure, aggressive diuresis should be done with loop diuretics (oral torsemide, bumetanide, or intravenous furosemide if bowel edema is suspected), thiazides, and aldosterone antagonists (especially in the presence of ascites and liver congestion).

When diuretics don’t help control symptoms, a pericardiectomy should be suggested. On the other hand, pericardectomy only removes the pericardium between the phrenic nerve pathways. After the procedure, most patients still need diuretics, but their symptoms usually get much better. Unfortunately, morbidity and death rates after pericardiectomy are high (up to 15%), and they are highest for people who were the sickest before the surgery.

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Some things that indicate a poor prognosis are having had radiation before, having kidney problems, having higher pulmonary systolic pressures, having an abnormal LV systolic function, having a lower serum sodium level, having liver problems, and being older. Pericardial calcium has no impact on survival.

If the diagnosis of constrictive pericarditis isn’t clear or if the symptoms of fluid retention don’t get better with medicine, a cardiologist should be referred to both figures out the diagnosis and suggest treatment.

I hope you understand constrictive pericarditis symptoms and treatment guidelines.

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