Makindo Medical Notes

Related Subjects: |Assessing Breathlessness |Assessing Chest Pain |Pericardial Effusion and Tamponade |Constrictive Pericarditis |Colchicine |Chest X Ray Interpretation

About

• A prominent x descent in the JVP may occur in constrictive pericarditis or pericardial effusion.
• The y descent is lost in tamponade but prominent in constrictive pericarditis
• Pathophysiology - think of a normal heart restricted within a small rigid box and the rigid box suddenly stops normal diastolic filling

Causes

• Idiopathic or Post-Viral Pericarditis: most commonly post viral infection.
• Infection control: Tuberculosis - Post pericardial effusion, calcification on CXR
• Inflammatory Rheumatoid disease, Autoimmune, Idiopathic
• Metabolic: Post surgical, Uraemia, Trauma, Post Cardiac surgery
• Malignancy: Pericardial malignancy, Mediastinal Radiation treatment
• DrugsDrug-induced: Procainamide and hydralazine, methysergide
• Trauma: Direct injury to the chest leads to pericardial damage and constriction.
• Tuberculosis: A common cause in developing countries, though less common in industrialized nations.
• Post-Cardiac Surgery or Radiation: Scarring of the pericardium can occur after cardiac surgery or radiation therapy to the chest.
• Connective Tissue Diseases: Conditions such as rheumatoid arthritis or systemic lupus erythematosus (SLE) can lead to pericardial inflammation and scarring.
• Uraemia: Severe kidney disease can lead to uremic pericarditis, which may progress to con

Aetiology

• Impaired ventricular filling during diastole and all cardiac diastolic pressures become nearly equal
• Pressures show a dip and plateau waveform "square root sign" - early rapid filling and sudden stop

Clinical

• Fatigue and weakness, ascites
• Breathlessness and orthopnea and pleural effusions
• Soft heart sounds and impalpable apex beat
• Patients have symptoms of right heart failure and poor cardiac output
• Pleural effusion, hepatomegaly, or ascites
• Elevated JVP, X and Y descent visible
• Pulsus paradoxus is a classical finding in cardiac tamponade, it is also be observed in severe constrictive pericarditis. Also severe asthma and COPD.
• Pulmonary oedema suggests another diagnosis
• Diastolic Pericardial knock (may be confused with S3) - sudden cessation of restricted ventricular filling
• Kussmaul's sign: JVP rises with inspiration (normally falls)
• Friedreich's sign: JVP has a steep y descent.

Differentiation from restrictive cardiomyopathy and cardiac tamponade can be difficult and may need several modalities in difficult cases

Investigations

• FBC, U&E, CRP: infection, TB, uraemia
• CXR: Pleural effusions common, signs of TB, calcified pericardial outline
• ECG: low QRS voltage, generalised T wave inversion or flattening, and P mitrale
• Echo: thickened bright pericardial changes
• Cardiac catheterisation shows the classical "square root sign" due to the abrupt halt in diastolic ventricular filling
• CT/MRI and biopsy to support the diagnosis

Management

• Medical Management: Diuretics for fluid overload. NSAIDs may be used in early stages or when inflammation is present.
• Surgical Management: definitive procedure is pericardiectomy, the surgical removal of the thickened pericardium. This can relieve symptoms and improve cardiac function, though it carries significant risks and is reserved for severe cases.

References

• ESC Guidelines for the diagnosis and management of pericardial diseases 2015