Medicine:Constrictive pericarditis

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Short description: Hardening of the membrane surrounding the heart
Constrictive pericarditis
Other namesPericarditis – constrictive
Constrictive pericarditis is defined by a thickened pericardium and decreased elasticity
SymptomsFatigue, difficulty breathing
CausesTuberculosis, Idiopathic/viral
Diagnostic methodCT scan, MRI
TreatmentAnti-inflammatory medication, Surgery

Constrictive pericarditis is a condition characterized by decreased elasticity and an increased thickening of the pericardium.[1] These changes reduce the ability of the heart to fill with blood and can lead to symptoms of heart failure.[1]

This condition may result from various disease processes which can have similar symptoms, and has been historically difficult to diagnose.[2] Understanding the differing etiologies and disease processes is important as it can lead to a timely diagnosis and appropriate treatment.[3]

Signs and symptoms

Constrictive pericarditis can present with symptoms such as difficulty breathing, fatigue, abdominal swelling, or swelling of legs.[1] Physical examination findings can include elevated Jugular venous pressure (JVP), Kussmaul's sign, Peripheral edema, Ascites, Hepatomegaly.[1] Auscultation of the heart may reveal a high-pitched sound during the heart's relaxation phase (Diastole) known as a pericardial knock.

Causes

In areas of the world where Tuberculosis is endemic, it is the most common cause of constrictive pericarditis.[4] Outside of these areas the next most common cause is typically idiopathic or viral in nature.[3] Causes of constrictive pericarditis can include:

Pathophysiology

Constrictive pericarditis

The pathophysiological characteristics of constrictive pericarditis are due to a thickened, fibrotic pericardium that forms a non-compliant shell around the heart. This shell prevents the heart from expanding when blood enters it. As pressure on the heart increases, the Stroke volume decreases as a result of a reduction in the ability of the heart to fill blood during Diastole. [7] This results in significant changes in blood flow based on the stage of respiration.[8]

During inspiration, pressure in the thoracic cavity decreases but is not relayed to the left atrium which can lead to a reduced flow to the left atrium and ventricle. During diastole, less blood flow in the left ventricle allows for more room for filling in right ventricle and therefore a septal shift occurs.[9]

During expiration, the amount of blood entering the left ventricle will increase, allowing the interventricular septum to bulge towards the right ventricle, decreasing the right heart ventricular filing.[10]

Classification

Constrictive pericarditis can be categorized into general syndromes that reflect the nature of the disease development and course.[11]

  • Transient (subacute) constrictive pericarditis: constrictive pathophysiology may be reversible due to a transient inflammatory state that resolves without significant fibrosis.[3]
  • Advanced (chronic) constrictive pericarditis: constrictive pathophysiology may be irreversible due to significant fibrosis and loss of elasticity over a longer period of time (often 3-6 months).[3]
  • Effusive-constrictive pericarditis: similar yet distinct disease process to constrictive pericarditis characterized by a constrictive pathophysiology and the presence of a pericardial effusion.[3]

Diagnosis

Tuberculosis-x-ray

The diagnosis of constrictive pericarditis is often difficult to make. In particular, restrictive cardiomyopathy has many similar clinical features to constrictive pericarditis, and differentiating them in a particular individual is often a diagnostic dilemma.[12]

  • Chest X-Ray - pericardial calcification (common but not specific), pleural effusions are common findings.[13]
  • Echocardiography - the principal echographic finding is changes in cardiac chamber volume.[13]
  • CT and MRI - CT scan is useful in assessing the thickness of pericardium, calcification, and ventricular contour. Cardiac MRI may find pericardial thickening and pericardial-myocardial adherence. Ventricular septum shift during breathing can also be found using cardiac MRI. Late gadolinium enhancement can show enhancement of the pericardium due to fibroblast proliferation and neovascularization.[10]
  • BNP blood test - tests for the existence of the cardiac hormone brain natriuretic peptide, which is only present in restrictive cardiomyopathy but not in constrictive pericarditis[14]
  • Conventional cardiac catheterization[15]
  • Physical examination - can reveal clinical features including Kussmaul's sign and a pericardial knock.[15]
X-ray demonstrating constrictive pericarditis with calcifications.

Treatment and Prognosis

Pericardium visualized in open heart surgery

Transient or subacute constrictive pericarditis is treated with anti-inflammatory medication and can resolve without surgical intervention in many cases.[3] Cases that do not resolve with medication may be treated similar to chronic constrictive cases which often require surgical intervention.[3] In these cases the outcome of surgery may be improved as the pericardial inflammation would be decreased due to the medication trial.[3]

The definitive treatment for advanced or chronic constrictive pericarditis is a radical Pericardiectomy, which is a surgical procedure in which the entire pericardium is peeled away from the heart. This procedure has significant risk involved,[16] with mortality rates of 6% or higher in major referral centers.[17]

A poor outcome is often the result after a pericardiectomy is performed for radiation-induced constrictive pericarditis, and some patients may develop heart failure post-operatively.[18]

Epidemiology

Constrictive pericarditis is a rare complication of many pericardial diseases.[11] It seen as a complication in approximately 1% of idiopathic pericarditis cases, and even fewer cases post cardiac surgery.[11]

The geographic distribution of constrictive pericarditis can be categorized based on etiology, with idiopathic or viral pericarditis considered to be the leading cause in Western countries.[11]In Western countries the remaining causes tend to be post-surgical, post-radiation, infectious, and connective tissue disorders.[11] In some developing countries Tuberculosis has been noted as the leading cause of constrictive pericarditis.[4]

References

  1. ↑ 1.0 1.1 1.2 1.3 Wang, Tom Kai Ming; Klein, Allan L.; Cremer, Paul C.; Imazio, Massimo; Kohnstamm, Sarah; Luis, Sushil Allen; Mardigyan, Vartan; Mukherjee, Monica et al. (2025-12-23). "2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on the Diagnosis and Management of Pericarditis". JACC 86 (25): 2691–2719. doi:10.1016/j.jacc.2025.05.023. PMID 40767817. https://www.jacc.org/doi/10.1016/j.jacc.2025.05.023. 
  2. ↑ Gillombardo, C. Barton; Hoit, Brian D. (April 2024). "Constrictive pericarditis in the new millennium". Journal of Cardiology 83 (4): 219–227. doi:10.1016/j.jjcc.2023.09.003. ISSN 0914-5087. PMID 37714264. https://linkinghub.elsevier.com/retrieve/pii/S0914508723002253. 
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Schulz-Menger, Jeanette; Collini, Valentino; Gröschel, Jan; Adler, Yehuda; Brucato, Antonio; Christian, Vanessa; Ferreira, Vanessa M; Gandjbakhch, Estelle et al. (2025-10-22). "2025 ESC Guidelines for the management of myocarditis and pericarditis" (in en). European Heart Journal 46 (40): 3952–4041. doi:10.1093/eurheartj/ehaf192. ISSN 0195-668X. PMID 40878297. https://academic.oup.com/eurheartj/article/46/40/3952/8234483. 
  4. ↑ 4.0 4.1 Dunn, Brian (2013). Manual of cardiovascular medicine (4th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 653. ISBN 978-1-4511-3160-4. https://books.google.com/books?id=ruhJv1tM-CUC&q=tuberculosis+causes+constrictive+pericarditis&pg=PA653. Retrieved 21 September 2015. 
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 "Constritive pericarditis". MedScape. http://emedicine.medscape.com/article/157096-overview#showall. 
  6. ↑ Lloyd, Joseph (2013). Mayo Clinic cardiology : concise textbook (4th ed.). Oxford: Mayo Clinic Scientific Press/Oxford University Press. p. 718. ISBN 978-0-199915712. https://books.google.com/books?id=WSCRAAAAQBAJ&q=pulmonary+asbestos++constrictive+pericarditis&pg=PA718. Retrieved 21 September 2015. 
  7. ↑ Yadav NK, Siddique MS. Constrictive Pericarditis. [Updated 2022 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459314/
  8. ↑ Crouch, Michael A. (2010). Cardiovascular pharmacotherapy : a point-of-care guide. Bethesda, Md.: American Society of Health-System Pharmacists. p. 376. ISBN 978-1-58528-215-9. https://books.google.com/books?id=U5MZBgAAQBAJ&q=constrictive+pericarditis+mechanism&pg=PT388. Retrieved 21 September 2015. 
  9. ↑ Camm, Demosthenes G. Katritsis, Bernard J. Gersh, A. John (2013). Clinical cardiology : current practice guidelines (1st ed.). Oxford: Oxford University Press. p. 388. ISBN 978-0-19-968528-8. https://books.google.com/books?id=1ZjrAQAAQBAJ&q=constrictive+pericarditis+definition&pg=PA388. Retrieved 21 September 2015. 
  10. ↑ 10.0 10.1 Welch, Terrence D.; Oh, Jae K. (November 2017). "Constrictive Pericarditis" (in en). Cardiology Clinics 35 (4): 539–549. doi:10.1016/j.ccl.2017.07.007. PMID 29025545. 
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Restelli, Davide; Carerj, Maria Ludovica; Bella, Gianluca Di; Zito, Concetta; Poleggi, Cristina; D’Angelo, Tommaso; Donato, Rocco; Ascenti, Giorgio et al. (October 2023). "Constrictive Pericarditis: An Update on Noninvasive Multimodal Diagnosis" (in en). Journal of Cardiovascular Echography 33 (4): 161–170. doi:10.4103/jcecho.jcecho_61_23. ISSN 2211-4122. PMID 38486689. 
  12. ↑ "Restrictive pericarditis". MedScape. http://emedicine.medscape.com/article/153062-differential. 
  13. ↑ 13.0 13.1 "Imaging in Constrictive pericarditis". MedScape. http://emedicine.medscape.com/article/348883-overview. 
  14. ↑ Semrad, Michal (2014). Cardiovascular Surgery. Charles University. p. 114. ISBN 978-80-246-2465-5. https://books.google.com/books?id=VaVxBgAAQBAJ&q=BNP+blood+test+constrictive+pericarditis&pg=PA114. Retrieved 21 September 2015. 
  15. ↑ 15.0 15.1 Khandaker, Masud H.; Espinosa, Raul E.; Nishimura, Rick A.; Sinak, Lawrence J.; Hayes, Sharonne N.; Melduni, Rowlens M.; Oh, Jae K. (June 2010). "Pericardial Disease: Diagnosis and Management". Mayo Clinic Proceedings 85 (6): 572–593. doi:10.4065/mcp.2010.0046. PMID 20511488. 
  16. ↑ "Chronic constrictive tuberculous pericarditis: risk factors and outcome of pericardiectomy". Int J Tuberc Lung Dis 10 (6): 701–6. 2006. PMID 16776460. 
  17. ↑ "Pericardiectomy for constrictive pericarditis: a clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques". Ann Thorac Surg 81 (2): 522–9. 2006. doi:10.1016/j.athoracsur.2005.08.009. PMID 16427843. 
  18. ↑ Greenberg, Barry H. (2007). Congestive heart failure (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. p. 410. ISBN 978-0-7817-6285-4. https://books.google.com/books?id=PV8A8282d2EC&q=constrictive+pericarditis+treatment&pg=PA410. Retrieved 21 September 2015. 

Further reading

Classification
External resources



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