Constrictive pericarditis

What it is

Constrictive pericarditis is chronic pericarditis that has left the pericardium fibrosed, thickened, adherent and/or calcified. The stiff pericardium is the whole of it: the right ventricle fills fast in early diastole and then suddenly halts against a non-compliant pericardium. On general examination it mimics CHF, and especially right-sided HF.

Causes and risk

Any cause of acute pericarditis may result in chronic pericarditis. The major causes are tuberculous, radiation-induced, post-cardiotomy and idiopathic; viral pericarditis, cardiac surgery and radiation therapy carry the same risk, and tuberculous pericarditis matters most in endemic areas.

How it presents

Dyspnea, fatigue and palpitations, dyspnea on exertion, and abdominal pain. The signs sit on the right side of the heart: ascites, hepatosplenomegaly, peripheral edema, and increased JVP. Blood pressure is normal to decreased.

Three bedside signs are the ones worth holding:

• Kussmaul's sign: an inspiratory rise in the jugular venous pulse, a paradoxical increase in JVP with inspiration.
• Friedreich's sign: a prominent y descent that is greater than the x descent in the jugular venous pulse, sharp and deep, from rapid early diastolic filling of the right ventricle that then suddenly halts.
• Pericardial knock: an early diastolic sound.

Pulsus paradoxus may or may not be present.