Constrictive Pericarditis Clinical Presentation

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

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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