Constrictive Pericarditis Clinical Presentation
- Author: John L Parks, MD; Chief Editor: Richard A Lange, MD, MBA more...
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:
Paroxysmal nocturnal dyspnea
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%).
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.
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.
Brockington GM, Zebede J, Pandian NG. Constrictive pericarditis. Cardiol Clin. 1990 Nov. 8(4):645-61. [Medline].
Shabetai R. Constrictive pericarditis. Shabetai R, ed. The Pericardium. New York, NY: Grune & Stratton; 1981.
Hancock EW. On the elastic and rigid forms of constrictive pericarditis. Am Heart J. 1980 Dec. 100(6 Pt 1):917-23. [Medline].
Shabetai R. Pericardial Disease: etiology, pathophysiology, clinical recognition, and treatment. New York NY: Churchill Livingstone; 1995. 1024-35.
Chen CA, Lin MT, Wu ET, et al. Clinical manifestations and outcomes of constrictive pericarditis in children. J Formos Med Assoc. 2005 Jun. 104(6):402-7. [Medline].
Bertog SC, Thambidorai SK, Parakh K, et al. Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy. J Am Coll Cardiol. 2004 Apr 21. 43(8):1445-52. [Medline].
Imazio M, Brucato A, Maestroni S, et al. Risk of constrictive pericarditis after acute pericarditis. Circulation. 2011 Sep 13. 124(11):1270-5. [Medline].
Griffin BP, Topol EJ. Pericardial Disease. Manual of Cardiovascular Medicine. 2nd ed. Philadelphia, Pennsylvania: Lippincott Williams and Wilkins; 2004. 372-396.
Thompson JL, Burkhart HM, Dearani JA, Cetta F, Oh JK, Schaff HV. Pericardiectomy for pericarditis in the pediatric population. Ann Thorac Surg. 2009 Nov. 88(5):1546-50. [Medline].
Babuin L, Alegria JR, Oh JK, Nishimura RA, Jaffe AS. Brain natriuretic peptide levels in constrictive pericarditis and restrictive cardiomyopathy. J Am Coll Cardiol. 2006 Apr 4. 47(7):1489-91. [Medline].
Leya FS, Arab D, Joyal D, et al. The efficacy of brain natriuretic peptide levels in differentiating constrictive pericarditis from restrictive cardiomyopathy. J Am Coll Cardiol. 2005 Jun 7. 45(11):1900-2. [Medline].
Yazdani K, Maraj S, Amanullah AM. Differentiating constrictive pericarditis from restrictive cardiomyopathy. Rev Cardiovasc Med. 2005. 6(2):61-71. [Medline].
Welch TD, Ling LH, Espinosa RE, et al. Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria. Circ Cardiovasc Imaging. 2014 May. 7(3):526-34. [Medline].
Sengupta PP, Mohan JC, Mehta V, Arora R, Khandheria BK, Pandian NG. Doppler tissue imaging improves assessment of abnormal interventricular septal and posterior wall motion in constrictive pericarditis. J Am Soc Echocardiogr. 2005 Mar. 18(3):226-30. [Medline].
Dal-Bianco JP, Sengupta PP, Mookadam F, Chandrasekaran K, Tajik AJ, Khandheria BK. Role of echocardiography in the diagnosis of constrictive pericarditis. J Am Soc Echocardiogr. 2009 Jan. 22(1):24-33; quiz 103-4. [Medline].
Appleton CP, Hatle LK, Popp RL. Cardiac tamponade and pericardial effusion: respiratory variation in transvalvular flow velocities studied by Doppler echocardiography. J Am Coll Cardiol. 1988 May. 11(5):1020-30. [Medline].
Hurrell DG, Nishimura RA, Higano ST, et al. Value of dynamic respiratory changes in left and right ventricular pressures for the diagnosis of constrictive pericarditis. Circulation. 1996 Jun 1. 93(11):2007-13. [Medline].
Sohn DW, Kim YJ, Kim HS, et al. Unique features of early diastolic mitral annulus velocity in constrictive pericarditis. J Am Soc Echocardiogr. 2004 Mar. 17(3):222-6. [Medline].
Veress G, Feng D, Oh JK. Echocardiography in pericardial diseases: new developments. Heart Fail Rev. 2012 Jul 1. [Medline].
Oh JK, Hatle LK, Seward JB, et al. Diagnostic role of Doppler echocardiography in constrictive pericarditis. J Am Coll Cardiol. 1994 Jan. 23(1):154-62. [Medline].
Zurick AO, Bolen MA, Kwon DH, Tan CD, Popovic ZB, Rajeswaran J, et al. Pericardial Delayed Hyperenhancement With CMR Imaging in Patients With Constrictive Pericarditis Undergoing Surgical Pericardiectomy A Case Series With Histopathological Correlation. JACC Cardiovasc Imaging. 2011 Nov. 4(11):1180-91. [Medline].
Amal L, Nawal D, Abdellah Z, Anis S, Fouad Amal W, Abdellatif B, et al. Use of magnetic resonance imaging in assessment of constrictive pericarditis: a Moroccan center experience. Int Arch Med. 2011 Oct 19. 4(1):36. [Medline].
Ariyarajah V, Jassal DS, Kirkpatrick I, Kwong RY. The utility of cardiovascular magnetic resonance in constrictive pericardial disease. Cardiol Rev. 2009 Mar-Apr. 17(2):77-82. [Medline].
Imazio M, Brucato A, Mayosi BM, et al. Medical therapy of pericardial diseases: part II: Noninfectious pericarditis, pericardial effusion and constrictive pericarditis. J Cardiovasc Med (Hagerstown). 2010 Nov. 11(11):785-94. [Medline].
Feng D, Glockner J, Kim K, et al. Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy: a pilot study. Circulation. 2011 Oct 25. 124(17):1830-7. [Medline].
Amaki M, Savino J, Ain DL, et al. Diagnostic concordance of echocardiography and cardiac magnetic resonance-based tissue tracking for differentiating constrictive pericarditis from restrictive cardiomyopathy. Circ Cardiovasc Imaging. 2014 Sep. 7(5):819-27. [Medline].
Hatle LK, Appleton CP, Popp RL. Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography. Circulation. 1989 Feb. 79(2):357-70. [Medline].
Talreja DR, Nishimura RA, Oh JK, Holmes DR. Constrictive pericarditis in the modern era: novel criteria for diagnosis in the cardiac catheterization laboratory. J Am Coll Cardiol. 2008 Jan 22. 51(3):315-9. [Medline].
Talreja DR, Edwards WD, Danielson GK, et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation. 2003 Oct 14. 108(15):1852-7. [Medline].
Imazio M, Antonio B, Roberto C, Ferrua S, Belli R, Maestroni S, et al. Colchicine treatment for recurrent pericarditis (CORP): a randomized trial. Ann Intern Med. 2011 Oct 4. 155(7):I28. [Medline].
Tuna IC, Danielson GK. Surgical management of pericardial diseases. Cardiol Clin. 1990 Nov. 8(4):683-96. [Medline].
Ling LH, Oh JK, Schaff HV, et al. Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation. 1999 Sep 28. 100(13):1380-6. [Medline].
[Guideline] Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, et al. Guidelines on the diagnosis and management of pericardial diseases. European Society of Cardiology. 2004.
Clare GC, Troughton RW. Management of constrictive pericarditis in the 21st century. Curr Treat Options Cardiovasc Med. 2007 Dec. 9(6):436-42. [Medline].