Making the diagnosis in more “typical” cases
Symptoms of constrictive pericarditis include fluid overload (eg, recurrent pleural effusions2-4) hepatic dysfunction, and peripheral edema. Studies show that 44% to 54% of patients with constrictive pericarditis present with pleural effusions;5 chest pain and dyspnea are other common symptoms.6 Past medical history is also important, considering the 3 most common risks for constrictive pericarditis: cardiac surgery, pericarditis, and irradiation of the mediastinum (TABLE).7
Typical physical exam findings in patients with constrictive pericarditis include an elevated jugular venous pressure, third spacing of fluids, a pericardial knock, and Kussmaul’s sign. Our patient had third spacing of fluids, including mild peripheral edema and the recurrent effusions as noted, as well as signs of hepatic dysfunction that were initially attributed to his rifampin use. While these symptoms raise the suspicion of constrictive pericarditis, none is specific to that condition alone.
Studies that help in the diagnosis of constrictive pericarditis include chest x-ray, cardiac CT, echocardiography, cardiac magnetic resonance imaging (MRI), and cardiac catheterization. EKG has no specific findings, but cardiac arrhythmias (eg, atrial fibrillation) are common.8 Pericardial thickening on cardiac CT scan is a definitive but not universal finding; in a Mayo Clinic study, such thickening was not evident in 26 of 143 patients with confirmed constrictive pericarditis.8 Cardiac MRI has been shown to have 88% sensitivity and 100% specificity,9 but will miss up to 18% of patients with constrictive pericarditis.8
Differentiating between restriction and constriction. It can be difficult to distinguish between constrictive pericarditis and restrictive cardiomyopathy. Although these conditions can present in a similar manner, they require different modes of treatment. Laboratory testing, cardiac catheterization, and tissue Doppler velocity echocardiography (which we relied on) can help to distinguish between them.
TABLE
Causes of constrictive pericarditis7
| More common |
|---|
| Idiopathic Postcardiac surgery (coronary artery bypass grafting, valve replacement) Postradiation therapy (eg, for breast cancer, lymphoma) Viral (pericarditis) |
| Less common |
| Asbestosis Cancer and myeloproliferative disorders Connective tissue disorders (rheumatoid arthritis, systemic lupus erythematosus) Adverse drug reaction Infection (tuberculosis, fungal) Sarcoidosis Trauma Uremia |
Pericardiectomy is the treatment of choice
Pericardiectomy, the optimal treatment for most patients with constrictive pericarditis, carries a 30-day perioperative mortality of approximately 6%.5,7 Patients with minimal symptoms can be monitored for up to 2 months, but only 17% of cases are self-limited.6 Patients with end-stage disease or those who have radiation-induced constrictive pericarditis experience poor surgical outcomes, and may be better served by medical management.7
In light of our patient’s excellent baseline functional status, clinical presentation, and Doppler test results, a cardiothoracic surgeon performed a pericardiectomy. His symptoms improved postoperatively, and he has had no further pleural effusions. The patient’s fatigue, anorexia, weight loss, and dyspnea fully resolved, as well.
PRACTICE POINTERS
- Include constrictive pericarditis in the differential diagnosis of patients with recurrent pleural effusions, an important presenting symptom in 44% to 54% of patients with this condition.
- Consider multiple testing modalities to arrive at a diagnosis of constrictive pericarditis, including cardiac CT or MRI, tissue Doppler echocardiography, and cardiac catheterization.
- Do not rule out constrictive pericarditis if pericardial thickening is not found on cardiac CT scan; in 1 study, this finding was not present in 18% of patients with a confirmed diagnosis.
CORRESPONDENCE Jeffrey S. Morgeson, MD; 2123 Auburn Avenue, 340 MOB, Cincinnati, OH 45219; morgesjs@gmail.com