Chronic pericarditis

Notes

Overview

Chronic pericarditis refers to long-standing inflammation (>3 months) of the pericardium that usually follows an acute episode.

Pericarditis refers to inflammation of the pericardial sac. It may be acute, incessant, or chronic.

  • Acute: an episode of acute pericardial inflammation
  • Incessant: pericardial inflammation lasting > 4-6 weeks but < 3 months
  • Chronic: pericardial inflammation lasting > 3 months

Aetiology

Chronic inflammation can occur after virtually any pericardial disease process.

Almost any cause of acute pericardial inflammation (e.g. viral, radiotherapy, drugs, tuberculosis) can lead to chronic inflammation.

Chronic pericarditis rarely occurs after an episode of acute idiopathic pericarditis (~1%). Chronic inflammation is more likely in patients with bacterial or tuberculosis pericarditis.

Pathophysiology

The main consequence of chronic inflammation of the pericardium is development of constrictive pericarditis.

Chronic inflammation leads to scarring and loss of the normal fibroelastic pericardial tissue. This can impede normal cardiac filling leading to features of right heart failure (raised JVP, peripheral oedema, tender hepatomegaly, exercise intolerance).

The development of constrictive pericarditis can be categorised into three clinical phenotypes:

  • Transient constriction: reversible constriction with resolution spontaneously or with medical therapy
  • Effusion-constriction: constrictive pericarditis with evidence of a pericardial effusion (features of constriction persist even after removal of pericardial fluid)
  • Chronic constriction: constriction > 3-6 months duration

These phenotypes represent a spectrum of pericardial disease following an acute episode:

  1. Acute pericarditis
  2. Pericardial effusion
  3. Chronic effusive pericarditis
  4. Effusive-constrictive pericarditis
  5. Chronic constrictive pericarditis

Clinical features

Patients characteristically present with features of right heart failure.

Symptoms

  • Shortness of breath
  • Leg swelling
  • Abdominal swelling
  • Exercise intolerance

Signs

  • Raised jugular venous pressure
  • Peripheral oedema
  • Ascites
  • Hepatomegaly

Diagnosis & investigations

The diagnosis of chronic constrictive pericarditis is made through imaging of the heart.

A variety of imaging modalities may be used to assess the heart including echocardiography, computed tomography, and magnetic resonance imaging.

These show impaired filling of the heart chambers during diastole and there may be features of chronicity including calcification.

Management

The treatment of chronic pericarditis is specialist.

The decision to treat a patient with chronic pericarditis depends on the extent of fibrosis and pathological phenotype.

Pericardiectomy is generally considered for patients with chronic constrictive pericarditis and severe symptoms of heart failure. This involves surgically removing the pericardial sac.

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