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Constrictive Pericarditis Clinical Presentation

  • Author: John L Parks, MD; Chief Editor: Richard A Lange, MD, MBA  more...
 
Updated: Dec 23, 2014
 

History

Because constrictive pericarditis presents with a myriad of symptoms, making a diagnosis solely on the basis of the clinical history is virtually impossible. Additionally, these symptoms may develop slowly over a number of years, so that patients may not be aware of all of their symptoms until questioned. Usually, the symptoms are similar to those associated with right-side congestive heart failure (CHF).

Dyspnea tends to be the most common presenting symptom and occurs in virtually all patients. Fatigue and orthopnea are common. Lower-extremity edema and abdominal swelling and discomfort are also common. Nausea, vomiting, and right upper quadrant pain, if present, are thought to be due to hepatic congestion, bowel congestion, or both.

The initial history may be more compatible with liver disease (cryptogenic cirrhosis) than with pericardial constriction because of the predominance of findings related to the venous system.

Chest pain, presumably due to active inflammation, may be present, though it is observed in only a minority of patients. Other symptoms that may be noted include the following:

  • Easy fatigability
  • Fever
  • Tachycardia
  • Palpitations
  • Paroxysmal nocturnal dyspnea
  • Diaphoresis

In a single-center review of pediatric patients who underwent pericardiectomy between 1978 and 2008, 11 patients underwent surgery for pericardial constriction; presenting complaints included chest pain in 4 (36%), shortness of breath in 2 (18%), and heart failure symptoms in 3 (27%).[10]

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Physical Examination

General findings

In the early stages, physical findings may be subtle, necessitating close examination to ensure that the diagnosis is not missed. In more advanced stages, the patient may appear ill, with marked muscle wasting, cachexia, or jaundice. Constriction should be considered in the presence of otherwise unexplained jugular venous distention, pleural effusion, hepatomegaly, or ascites.

Cardiovascular findings

Elevated jugular venous pressures are an almost universal finding. Avoid examining the patient only in the supine position, because venous pressures may be above the angle of the jaw and inadvertently mistaken for normal.

Sinus tachycardia is common while the blood pressure is normal or low, depending on the stage of the disease process.

The apical impulse is often impalpable, and the patient may have distant or muffled heart sounds. A friction rub is usually not found.

A pericardial knock, which corresponds with the sudden cessation of ventricular filling early in diastole, occurs in approximately half the cases. It is usually heard along the left sternal border and may be mistaken for an S3 gallop. However, a knock is of higher frequency than an S3 gallop and occurs slightly earlier in diastole.

A cardiac murmur is typically not present unless concomitant valvular heart disease or a fibrous band that constricts the right ventricular outflow tract is present.

Pulsus paradoxus is a variable finding. If present, it rarely exceeds 10 mm Hg unless a concomitant pericardial effusion with an abnormally elevated pressure exists.

The Kussmaul sign (ie, elevation of systemic venous pressures with inspiration) is a common nonspecific finding, but this sign is also observed in patients with right ventricular failure, restrictive cardiomyopathy, right ventricular infarction, and tricuspid stenosis—though, notably, not in patients with cardiac tamponade.

Right-sided heart cardiac catheterization provides direct assessment of cardiac filling pressures and can be invaluable in diagnosing constriction, helping to correlate physical examination findings with quantitative data. Ventricular pressure waveform typically demonstrates a steep y descent after systole, followed by rapid diastolic filling (during early diastole) until a plateau is reached. There is little additional filling of the ventricle despite atrial contraction. This corresponds to a normally compliant ventricle opening and rapid filling initially until the stiff pericardium impedes late diastolic filling (forming the so-called “dip-and-plateau” sign).

Gastrointestinal, pulmonary, and other organ system findings

Hepatomegaly with prominent hepatic pulsations can be detected in as many as 70% of patients. Other signs that result from chronic hepatic congestion include ascites, spider angiomata, and palmar erythema, which can contribute to the common but erroneous diagnosis of primary liver disease.

Peripheral (dependent) edema is a common finding, though it may be less prominent in younger patients with competent venous valves.

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Contributor Information and Disclosures
Author

John L Parks, MD Fellow, Division of Cardiology, Medical University of South Carolina College of Medicine

John L Parks, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Terrence X O'Brien, MD, FACC Professor of Medicine/Cardiology, Director, Clinical Cardiovascular Research, Medical University of South Carolina; Director, Echocardiography Laboratory, Veterans Affairs Medical Center of Charleston

Terrence X O'Brien, MD, FACC is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, Heart Failure Society of America, American Heart Association, South Carolina Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Acknowledgements

Hugh D Allen, MD Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine

Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, and Western Society for Pediatric Research

Disclosure: Nothing to disclose.

Stuart Berger, MD Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Charles I Berul, MD Professor of Pediatrics and Integrative Systems Biology, George Washington University School of Medicine; Chief, Division of Cardiology, Children's National Medical Center

Charles I Berul, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, Pediatric and Congenital Electrophysiology Society, and Society for Pediatric Research

Disclosure: Johnson & Johnson Consulting fee Consulting

Christopher Johnsrude, MD, MS Chief, Division of Pediatric Cardiology, University of Louisville School of Medicine; Director, Congenital Heart Center, Kosair Children's Hospital

Christopher Johnsrude, MD, MS is a member of the following medical societies: American Academy of Pediatrics and American College of Cardiology

Disclosure: St Jude Medical Honoraria Speaking and teaching

Renee E Margossian, MD Instructor, Department of Cardiology, Children's Hospital, Harvard University; Consulting Staff, Department of Cardiology, Boston Medical Center and Brigham and Women's Hospital

Renee E Margossian, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Society of Echocardiography, and Heart Failure Society of America

Disclosure: Nothing to disclose

Ronald J Oudiz, MD, FACP, FACC, FCCP Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, and American Thoracic Society

Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Encysive Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria; Lilly Grant/research funds Clinical Trials + honoraria; LungRx Clinical Trials + honoraria; Bayer Grant/research funds Consulting

Weems R Pennington III, MD Cardiology Fellow, Department of Medicine, Medical University of South Carolina

Disclosure: Nothing to disclose.

Kurt Pflieger, MD, FAAP Active Staff, Department of Pediatrics, Lake Pointe Medical Center

Kurt Pflieger, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Darren S Sidney, MD, MS Electrophysiology Fellow, Department of Medicine, Medical University of South Carolina

Disclosure: Nothing to disclose.

Brian D Soriano, MD, FASE, Associate Professor of Pediatrics, Cardiology Division, Adjunct Assistant Professor of Radiology, University of Washington School of Medicine; Attending Physician, Pediatric Cardiology and Cardiac Imaging, Seattle Children’s Hospital

Brian D Soriano is a member of the following medical societies: American Heart Association, American Medical Association, and American Society of Echocardiography

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric Vanderbush, MD, FACC Chief, Department of Internal Medicine, Division of Cardiology, Harlem Hospital Center; Clinical Assistant Professor of Cardiology, Columbia University College of Physicians and Surgeons

Eric Vanderbush, MD, FACC is a member of the following medical societies: American College of Cardiology and American Heart Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Acknowledgments

Acknowledgments for this work include support by the Office of Research and Development, Medical Research Service, Ralph H. Johnson Department of Veterans Affairs Medical Center, and the Gazes Cardiac Research Institute, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.

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Constrictive pericarditis. Anteroposterior and lateral chest radiograph from a patient with tuberculous constrictive pericarditis (arrows denote marked pericardial calcification).
Right atrial pressure tracing showing marked y descents (arrows) in a patient with constrictive pericarditis.
Simultaneous right and left ventricular pressure tracings showing diastolic equalization of pressures in both ventricles in a patient with constrictive pericarditis.
MRI shows constrictive pericarditis in 13-year-old patient with otherwise structurally normal heart. Infectious workup was negative. (Image courtesy of Tal Geva, MD.)
Left ventricular volume curve in constrictive pericarditis.
 
 
 
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