Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ KEY FEATURES +++ ESSENTIALS OF DIAGNOSIS ++ MRI, CT, or echocardiographic imaging showing a thickened pericardium Right heart failure signs and symptoms due to impaired diastolic filling Kussmaul sign and pericardial knock on exam Echocardiogram shows septal bounce, respiratory variation of the mitral peak E velocity Cardiac catheterization shows “dip and plateau” or “square-root” sign +++ GENERAL CONSIDERATIONS ++ Results from scarring as the aftermath of almost any pericardial injury or inflammation In developed countries, the most common etiologies are idiopathic or viral, followed by post–cardiac surgery, post–radiation therapy, and connective tissue disorders In developing countries, tuberculosis remains a major cause Pericardium becomes thickened, fibrotic, and sometimes calcified (especially with tuberculosis) The noncompliant pericardium encases the heart and results in a fixed cardiac volume Diastolic filling is abruptly halted in early diastole when the volume limit of the noncompliant pericardium is attained It is sometimes difficult to distinguish from restrictive cardiomyopathy but is important to do so because constriction may be cured with pericardiectomy Some patients have normal pericardial thickness Some patients undergo spontaneous resolution or respond to medical therapy Although most patients have relief of symptoms after pericardiectomy, some do not +++ CLINICAL PRESENTATION +++ SYMPTOMS AND SIGNS ++ Fatigue Dyspnea Increased abdominal girth Edema Malabsorptive diarrhea Chest pain Dizziness +++ PHYSICAL EXAM FINDINGS ++ Markedly elevated jugular venous pressure (JVP) with x and y troughs more prominent than the a and v peaks Pulsus paradoxus in some Kussmaul sign (lack of inspiratory decline in JVP) Pericardial knock (early diastolic sound) on auscultation Abdominal distention with fluid wave from ascites Pulsatile hepatomegaly Profound cachexia Edema or anasarca +++ DIFFERENTIAL DIAGNOSIS ++ Cardiac tamponade Restrictive cardiomyopathy Right heart failure Cirrhosis with ascites Malabsorption syndrome +++ DIAGNOSTIC EVALUATION +++ LABORATORY TESTS ++ Antinuclear antibody titer Rheumatoid factor Tuberculin skin test +++ ELECTROCARDIOGRAPHY ++ No specific ECG findings with constriction Nonspecific ST- and T-wave changes common Low voltage sometimes present Atrial fibrillation common in advanced cases P mitrale common in less severe and less chronic cases +++ IMAGING STUDIES ++ Chest x-ray: pericardial calcification is specific but uncommon MRI is the procedure of choice to image pericardial thickness CT is also extremely useful Echocardiography is an essential adjunctive test – Abrupt rapid movement of the interventricular septum during inspiration, termed “septal bounce,” and moderate biatrial enlargement – Doppler mitral E velocity is typically increased, and exaggerated respirophasic variation in mitral inflow (mitral E velocity decreases by at least 25% with inspiration) is characteristic. The inferior vena cava is dilated and does not collapse with inspiration. Hepatic vein flow does not increase with inspiration +++ DIAGNOSTIC PROCEDURES +... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth