eMedicine Specialties > Cardiology > Pericardial Disease

Pericarditis, Constrictive: Treatment & Medication

Author: Darren S Sidney, MD, MS, Cardiology Fellow, Department of Medicine, Medical University of South Carolina
Coauthor(s): Terrence X O'Brien, MD, FACC, Office of Research and Development, Ralph H Johnson Veterans Affairs Medical Center; Professor, Department of Medicine, Division of Cardiology, Medical University of South Carolina
Contributor Information and Disclosures

Updated: Jul 8, 2008

Treatment

Medical Care

  • Medical management is generally ineffective in the vast majority of cases unless a prominent inflammatory component is present.
  • This is in contrast with acute pericarditis (see Pericarditis, Acute), in which the use of nonsteroidal anti-inflammatory agents, cyclooxygenase-2 inhibitors, colchicine, corticosteroids, or a combination thereof may provide benefit. However, even after optimal therapy of acute pericarditis, over time, the possibility of developing constriction exists. Other medical considerations are as follows:
    • Subacute constrictive pericarditis may respond to steroids if treated before pericardial fibrosis occurs.
    • Diuretics are commonly used to relieve congestion if ventricular filling pressures are clinically elevated. However, this may decrease cardiac output and requires careful monitoring.
    • Any therapy directed toward the causative disease is appropriate, such as antituberculosis medication.
    • Complications, such as atrial arrhythmias, require their own therapy as needed.
    • In general, beta-blockers and calcium channel blockers should be avoided because the sinus tachycardia that commonly occurs in constrictive pericarditis is compensatory in nature, maintaining cardiac output in a setting of fixed stroke volume (secondary to fixed diastolic filling).

Surgical Care

  • Complete pericardectomy is the definitive therapy and is a potential cure.23,24,26
    • Results are generally better if the procedure is performed earlier in the course, when less calcification is present and when the chance of abnormal myocardium or advanced heart failure is reduced.
    • Some judgment is required because patients who are asymptomatic (NYHA class I) or who have early NYHA stage II symptoms may be clinically stable for years.
    • Pericardial decortication should be as extensive as possible, especially at the diaphragmatic-ventricular contact regions. The surgical procedure can be long and is often technically complex. Complications may include excessive bleeding, atrial and ventricular arrhythmias, and ventricular wall ruptures. The 2 standard approaches are the anterolateral thoracotomy and a median sternotomy. Additionally, an excimer laser can be used severe adhesions occur between the pericardium and epicardium.26
    • The published surgical mortality rates range from 5-15%. Most recently, the perioperative mortality rate (within 30 days) was found to be 6.1%. The causes of death include progressive heart failure, sepsis, renal failure, respiratory failure, and arrhythmia. Significantly, 80-90% of patients who undergo pericardectomy  achieve NYHA class I or II postoperatively.
    • Even though the symptoms following a pericardiectomy are commonly improved, evidence of abnormal diastolic filling (which can be correlated with clinical status) often remains. Only 60% of patients have complete normalization of cardiac hemodynamics.26 Although some improved with time, persistent diastolic filling abnormalities tended to occur in patients who had a longer history of preoperative symptoms, supporting the concept of early operation in patients who are symptomatic.
    • In 58 patients who underwent total pericardectomy for constriction, 30% still had some significant symptoms after 4 years. These patients were more likely to have a persistent restrictive or constrictive pattern to their transmitral and transtricuspid Doppler signals as determined by respiratory recording.
    • New experimental devices are being investigated to access the pericardial space, including use in patients without significant effusions. Hopefully, the development of such devices, such as video-assisted thorascopy, can improve diagnostic and therapeutic options in patients with pericardial disease.25
    • Cardiac mortality and morbidity seems to be related to presurgical myocardial atrophy or fibrosis, which can be detected using CT. Excluding these patients keeps the mortality rate at the lower end of the range (5%).26
    • Postoperative low cardiac output can be treated in the usual fashion, including vasoactive pressors and intra-aortic balloon pump (IABP), if necessary.

Consultations

  • A cardiologist can assist with obtaining and interpreting echocardiographic imaging, hemodynamic measurements, and, if necessary, endocardial or pericardial biopsies.
  • Consultation with a cardiothoracic surgeon is appropriate when a pericardial procedure is being considered.

Diet

  • A low salt, fluid-restricted diet is probably beneficial.

Activity

  • Although no specific restrictions are needed, activity can often be severely limited by symptoms.

Medication

Surgical pericardectomy is clearly the treatment of choice for patients with constrictive pericarditis. Diuretics have been used in the early stages of the disease to improve pulmonary and systemic congestion. However, these should be used cautiously because any drop in intravascular volume may cause a corresponding drop in cardiac output.

Diuretics

These agents may improve pulmonary and systemic congestion. These should be used cautiously because any drop in intravascular volume may cause a corresponding drop in cardiac output.


Furosemide (Lasix)

Any loop diuretics may be used to treat volume overload. Always start at minimal dose necessary.

Adult

20 mg/d PO/IV

Pediatric

Not established

Metformin decreases concentrations; interferes with hypoglycemic effect of antidiabetic agents and antagonizes muscle-relaxing effect of tubocurarine; auditory toxicity appears to be increased with coadministration of aminoglycosides; hearing loss of varying degrees may occur; anticoagulant activity of warfarin may be enhanced when taken concurrently; increased plasma lithium levels and toxicity are possible when taken concurrently

Documented hypersensitivity; hepatic coma; anuria; state of severe electrolyte depletion

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Perform frequent serum electrolyte, carbon dioxide, glucose, creatinine, uric acid, calcium, and BUN level determinations during first few months of therapy and periodically thereafter

More on Pericarditis, Constrictive

Overview: Pericarditis, Constrictive
Differential Diagnoses & Workup: Pericarditis, Constrictive
Treatment & Medication: Pericarditis, Constrictive
Follow-up: Pericarditis, Constrictive
Multimedia: Pericarditis, Constrictive
References
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References

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Further Reading

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Keywords

constrictive pericarditis, pericardium, acute pericarditis, chronic pericarditis, pericarditis, diastolic filling, restrictive cardiomyopathy, calcific constrictive pericarditis, pericardial effusion, pericardial organization, chronic fibrotic scarring, calcification, restricted cardiac filling, idiopathic pericarditis, infectious pericarditis, radiation-induced pericarditis, postsurgical pericarditis, postmyocardial infarction pericarditis, Kussmaul sign, tuberculosis, tuberculous pericarditis, postradiation constrictive pericarditis, cardiac surgery, pericardiectomy, pericardial constriction, viral pericarditis, coxsackievirus A, coxsackievirus B, echoviruses, adenoviruses, purulent pericarditis, coronary artery bypass grafting, neoplasms, uremia, connective tissue disorders, drug-induced pericarditis, chylopericardium, bacterial pericarditis, fungal pericarditis

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Contributor Information and Disclosures

Author

Darren S Sidney, MD, MS, Cardiology Fellow, Department of Medicine, Medical University of South Carolina
Disclosure: Nothing to disclose.

Coauthor(s)

Terrence X O'Brien, MD, FACC, Office of Research and Development, Ralph H Johnson Veterans Affairs Medical Center; Professor, Department of Medicine, Division of Cardiology, Medical University of South Carolina
Terrence X O'Brien, MD, FACC is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Eric Vanderbush, MD, Chief, Department of Internal Medicine, Division of Cardiology, Clinical Assistant Professor, Harlem Hospital Center and Columbia University
Eric Vanderbush, MD is a member of the following medical societies: American College of Cardiology and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Ronald J Oudiz, MD, Director of Pulmonary Hypertension, Associate Professor, Department of Medicine, Division of Cardiology, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA
Ronald J Oudiz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association
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

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

George A Stouffer III, MD, Henry A Foscue Distinguished Professor of Medicine and Cardiology, Director of Interventional Cardiology, Cardiac Catheterization Laboratory, Chief of Clinical Cardiology, Division of Cardiology, University of North Carolina Medical Center
George A Stouffer III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
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