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Constrictive pericarditis

Definition
Constrictive pericarditis is a chronic disease characterized by symptoms of fluid overload, progressive reduction in cardiac output, and congestive HF.
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Pathophysiology
Constrictive pericarditis is caused by fibrous thickening of the pericardium due to idiopathic reasons, prior cardiac surgery, postradiotherapy, postinfection (tuberculosis and non-tuberculous bacterial infection), connective tissue disease, malignancy, uremia, and sarcoidosis.
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Disease course
Chronic fibrous thickening of the pericardium due to various infectious and non-infectious causes result in constrictive pericarditis, which causes clinical manifestations of dyspnea, peripheral edema, chest pain, palpitation, abdominal distension, fever, fatigue, weight loss, jugular venous distension, pulsus paradoxus, hepatosplenomegaly, ascites, Kussmaul's sign, and pericardial shock.
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Prognosis and risk of recurrence
In-hospital mortality associated with constrictive pericarditis is 2.1%.
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Key sources
The following summarized guidelines for the evaluation and management of constrictive pericarditis are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2021) and the European Society of Cardiology (ESC/EACTS 2015).
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Guidelines

1.Diagnostic investigations

Initial evaluation: evaluate all patients with suspected pericardial disease using auscultation, ECG, TTE, CXR and routine blood tests, including markers of inflammation such as CRP and/or ESR, WBC count with differential, renal function, liver tests, and cardiac biomarkers.
B
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  • Transthoracic echocardiography

  • CXR

  • Cardiac MRI/CT

2.Diagnostic procedures

Diagnostic pericardiocentesis: perform diagnostic pericardiocentesis with cytological analyses of pericardial fluid to confirm malignant pericardial disease.
B

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  • Cardiac catheterization

3.Medical management

Empiric antibacterial therapy: initiate intravenous antibiotic therapy in patients with purulent pericarditis.
B

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  • Empiric anti-inflammatory therapy

  • Empiric anti-tuberculous therapy

4.Therapeutic procedures

Intrapericardial urokinase: consider administering intrapericardial urokinase to reduce the risk of constriction in tuberculous effusive pericarditis.
C

5.Surgical interventions

Indications for pericardiectomy: refer patients with chronic, permanent constriction for pericardiectomy when clinically appropriate.
B

6.Specific circumstances

Patients with tuberculous pericarditis: administer standard antituberculosis drugs for 6 months for the prevention of tuberculous pericardial constriction.
B
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  • Patients with purulent pericarditis

  • Patients with radiation-induced constrictive pericarditis