Critical Care Medicine-Neurologic Disorders>>>>>Pericardial Diseases
Question 3#

A 62-year-old woman with a history of acute pericarditis 4 years ago that was treated with nonsteroidal anti-inflammatory drug (NSAID) to complete resolution presents with 8 weeks of insidiously worsening fatigue, bilateral lower extremity edema, breathlessness, and a feeling of abdominal fullness. She denies any fevers, chest pain, palpitations, or light-headedness. Physical examination is remarkable for 2+ pitting bilateral lower extremity edema, elevated jugular venous pressure with a rapid y descent, and an early diastolic sound best heard at the apex. Echocardiography shows normal right and left ventricular systolic function, a thickened pericardium without pericardial effusion, moderate left-sided pleural effusion, inspiratory ventricular septal motion toward the left ventricle, along with marked dilatation and absent respirophasic collapse of the inferior vena cava and hepatic veins.

The therapy most likely to yield relief of the patient’s symptoms is:

a. High-dose NSAIDs and colchicine
b. Corticosteroids
c. Percutaneous coronary intervention
d. Pericardiectomy
e. Reassurance

Correct Answer is D

Comment:

Correct Answer: D

This patient’s clinical picture, along with signs on physical examination and diagnostic testing, are most consistent with constrictive pericarditis. The definitive treatment of constrictive pericarditis is surgical pericardiectomy. Constrictive pericarditis is the result of inflammatory injury to the pericardium arising from a plethora of causes. The risk of progressing to constrictive pericarditis is very low with most etiologies of pericardial disease, ranging from 1% in viral and idiopathic pericarditis, but up to 20% to 30% in bacterial and purulent pericarditis. Tuberculosis is a major cause of constrictive pericarditis in the developing world.

The clinical presentation of constrictive pericarditis is due to manifestations of impaired diastolic filling of both ventricles. The rigid pericardium lacks compliance, and as a result, leads to diastolic constraint on the heart with preserved ventricular function; accordingly, constrictive pericarditis is on the differential diagnosis for a heart failure with preserved ejection fraction syndrome. Signs and symptoms of right heart failure are the most prominent manifestations of constrictive pericarditis. This includes venous and hepatic congestion, hepatomegaly, and ascites. There can be significant tricuspid regurgitation present. Pleural effusions may also be seen.

References:

  1. Imazio M, Brucato A, Maestroni S, et al. Risk of constrictive pericarditis after acute pericarditis. Circulation. 2011;124:1270-1275.
  2. Welch TD, Ling LH, Espinosa RE, et al. Echocardiographic diagnosis of constrictive pericarditis: mayo clinic criteria. Circ Cardiovasc Imaging. 2014;7:526-534. 3. Biçer M, Özdemir B, Kan İ, et al. Long-term outcomes of pericardiectomy for constrictive pericarditis. J Cardiothorac Surg. 2015;10:177.