Chronic Constrictive Pericarditis

Background

• Due to progressive thickening, fibrosis and calcification of the pericardium, causing a restrictive cardiac filling defect.
  • Fibrosis may also spread into the myocardium to cause impairment of heart contraction also

Aetiology

• The risk factors/causes for chronic pericarditis are essentially the same as in acute disease but the course is prolonged
  • Risk is significantly higher in bacterial (particularly TB) pericarditis
  • Post-pericardectomy syndromes/systemic inflammatory conditions carry a small (but increased) risk
  • Risk for developing chronic pericarditis is low following viral pericarditis
• NB Often, there will be no underlying insult found

Presentation

• NB Difficult diagnosis based on clinical findings alone.
• Signs of venous congestion e.g. elevated JVP (can be markedly high; classically with a rapid y descent; also can rise with inspiration- Kussmaul’s sign); hepatomegaly; ascites; peripheral oedema
  • Signs of venous congestion without an enlarged heart or valvular disease (i.e. no murmurs) should suggest the possibility of constrictive pericarditis
• Fatigue
• Pulse: may be rapid, low-volume
• BP: may show pulsus paradoxicus (a paradoxical and excessive fall in BP with inspiration)
• NOTE: Chest pain and breathlessness are uncommon in these patients

Investigations

• CXR- may show calcification of the pericardium
• Echocardiogram is often diagnostic
• Other imaging studies and ECG may be helpful

Management

• If there is an identifiable and treatable underlying cause, treat this in the first instance.
• Pericardectomy may be required in patients with severe disease.  However, this is a very risky procedure and results are variable