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Clinical tips in cardiology : Differential diagnosis for constrictive pericarditis .

Posted Jun 14 2012 1:15pm

A  patient who presents with predominantly right  heart failure  is  an interesting clinical challenge . Constrictive pericarditis (CP)  remains  a popular diagnosis in this setting. However  in the bed side clinical  examination (and in cardiology Board exams )  the following  differential diagnoses are  to be  considered .( And ruled out one by one)

  1. Restrictive cardiomyoapthy* especially Right  sided .In India endo myocardial fibrosis tops the list
  2. Primary Tricuspid valve disease( Tricuspid stenosis / Carcinoid etc)
  3. Chronic cor-pulmonale in terminal RV failure
  4. Silent Mitral stenosis with right heart failure
  5. Ebstein anomaly
  6. Severe forms of valvular pulmonary stenosis with RV dysfunction
  7. SVC obstruction
  8. Cirrhosis of liver
  9. Porto pulmonary hypertension

( The list is not complete , readers may contribute )

Bed side clues

  • Remember  a deep “y” descent  is  the bed side counter part of   Square root sign  recorded by  invasive RV pressure study
  • Similarly , pericardial knock is the auditory   equivalent (You hear the square root !  . . .yes  )as the ventricle thuds the rigid thickened pericardial shell in very early diastole !)
  • Pulsus paradoxus and kussmal sign can occur in both CP and RCM.
  • If a good LV apex , is  palpated it  goes against CP .
  • Please be reminded , even restrictive cardiomyopathy  will ultimately dilate their chamber pre-terminal and clinical features may be confounded with that of DCM.
  • Silent heart would suggest CP.
  • AV valve regurgitation would favor RCM
  • Features of  Pulmonary hypertension will help confirm Mitral valve disease , Cor pulmonale,
  • Deep  “y”descents  are against  any form of  Tricuspid stenosis.
  • Opening snap of mitral valve is to be distinguished from pericardial knock.( Opening snap high pitched  and occur later than   pericardial knock in diastole   , best heard in expiration )
  • Cirrohis liver with hypo- proteinimic   fluid retention is  a traditionally close mimicker  .It  may be ruled out by the careful history taking as exertional dyspnea is an exception , if  at all , it is a very late event  in cirrhosis.
  • The issue gets further weird   as chronic constriction can lead on to chronic congestive liver and cardiac cirrhosis .
  • Severe  forms of constriction can invade the myocardium and result in features of myocardial dysfunction .It is more common than we recognise.

How to confirm ?

Following should be performed in that order

  • ECG
  • X -Ray
  • Echocardiogram
  • CT scan
  • MRI

*Cath study is no longer done (Only for academic purpose )

Final message

Even in this era of sophisticated  medical  imaging  , clinical examination  remains the key . One should  realise the importance  of  meticulous  clinical history  ,  sequential examination and interpretation .It  will   “rule out  or rule in“  majority of  cardiac disorders .

The hi tech imaging  modalities should be used only to confirm , risk stratify and  plan management . If you skip the clinical  part , one  may still arrive at a correct  diagnosis  but there is  high chances of erring in  management.

( A  clinical pearls lie in the bed side not in cath labs !   Here is  one such pearl  . Not every constriction  require surgery !

Please note about 20 % of constrictive pericardits are  transient !)


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