Constrictive Pericarditis - intrinsic Flashcards
What is constrictive pericarditis?
characterized by a thickened, fibrotic pericardium, limiting the heart’s ability to function normally (impairs optimal relaxation and hence filling)
What is the pathological process that iniates the development of constrictive pericarditis?
prolonged inflammation
- immune cells initiate fibrosis of serous (inner visceral) pericardium
- –> stiffening of heart tissue - forms hard shell around heart
- –> impairs expansion of ventricles, and hence filling
- –> reduces stroke volume
What is another process linked to filling of the ventricles, that occurs in constrictive pericarditis?
ventricular interdependence caused by respiratory variation in blood flow in the chambers of the heart
How does respiratory variation in blood flow to chamber of the heart occur?
inspiration
- lowers pressure in thoracic cavity, but isn’t relayed to left atrium
- –> a reduction in flow to left atrium & ventricle happens.
- During diastole, less blood flow in left ventricle allows for more room for filling in right ventricle
- –> septal shift occurs
expiration
- amount of blood entering right ventricle will decrease
- allowing septum to bulge towards right ventricle (septal shift)
- –> increased filling of left ventricle
- –> increased pressure generated by left ventricle during systole
What cause of constrictive pericarditis has the highest incidence of the disease?
TB has the HIGHEST TOTAL INCIDENCE out of all causes
What are the risk factors for constrictive pericarditis?
- previous episode of pericarditis
- incomplete drainage of purulent pericarditis
- Chronic pericarditis
- post-MI
- post-cardiotomy
Summarise the epidemiology of constrictive pericarditis
- most cases occur 3-12 months post-pericardial insult e.g. infectious pericarditis / pericardial effusion
- relatively rare complication of pericarditis / pericardial effusion
- 9% of patients with acute pericarditis will develop constrictive pericarditis
- males > females
What are the presenting symptoms of constrictive pericarditis?
EARLY disease ~ be subtle - disease onset is gradual
fluid overload:
- peripheral oedema
- swollen abdomen (ascites?)
lower CO:
- dyspnoea
- fatigue
- myalgia
What are the signs of constrictive pericarditis seen O/E?
RHF signs:
- raised JVP
- Pulsus paradoxus (drop in JVP on inspiration)
- Kussmaul’s sign
- Dyspnoea
- peripheral oedema
- pulsatile hepatomegaly
- pericardial knock
- ascites
- ~ cachexia
What is Kussmaul’s sign?
lack of an inspiratory decline in JVP
BUT could also be severe tricuspid valve disease or right-sided HF
What is a pericardial knock?
A medium frequency accentuated heart sound occurring ~earlier than an S3
- may be audible
- rarely palpable
(due to rapid ventricular filling)
Which other condition has a similar presentation to constrictive pericarditis?
restrictive cardiomyopathy
What are the primary investigations for ?constrictive pericarditis
bloods
-
BNP
- will be normal, unlike in cardiomyopathy
imaging
-
CXR
- may see pericardial calcification
- may see pericardial effusions
What are some secondary investigations for ?constrictive pericarditis
-
Transthoracic echocardiography (TTE)
- Increased pericardial thickness
-
Doppler echocardiography
- abnormal filling
-
MRI
- increased pericardial thickness
- calcification
-
CT
- same as MRI
- ~ Pericardial biopsy
Which investigations are the most important for making a diagnosis of constrictive pericarditis?
-
Transthoracic echocardiography (TTE)
- Increased pericardial thickness
-
Doppler echocardiography
- abnormal filling
