Constrictive pericarditis differential diagnosis: Difference between revisions
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{{ | __NOTOC__ | ||
{{CMG}} | {{Constrictive pericarditis}} | ||
{{CMG}}; {{AE}} {{Hudakarman}} | |||
==Overview== | ==Overview== | ||
[[Constrictive pericarditis]] must be differentiated from [[restrictive cardiomyopathy]]. The evaluation of ventricular interdependence between the two ventricles is the best objective method to distinguish the two syndromes. | [[Constrictive pericarditis]] must be differentiated from [[restrictive cardiomyopathy]]. The evaluation of [[ventricular]] interdependence between the two [[ventricles]] is the best objective method to distinguish the two [[syndromes]]. Constrictive pericarditis should also be differentiated from cardiac tamponade, right-sided atrial tumors, such as myxomas, superior vena cava syndrome, right-sided valvular abnormalities (tricuspid stenosis or tricuspid regurgitation), systolic or diastolic congestive heart failure( pressure-overload and myocardial, valvular, or atherosclerotic disease causes) | ||
==Pathophysiology== | ==Pathophysiology== | ||
Both syndromes are associated with abnormalities in left ventricular filling. In patients with constriction, this is due to constriction of filling of the left ventricle by the pericardium. In restriction, there is impaired relaxation of the left ventricle. | Both [[syndromes]] are associated with abnormalities in [[left ventricular]] filling. In patients with [[constriction]], this is due to [[constriction]] of filling of the [[left ventricle]] by the [[pericardium]]. In [[restriction]], there is impaired [[relaxation]] of the [[left ventricle]]. | ||
==Ventricular Interdependence== | ==Ventricular Interdependence== | ||
Ventricle interdependence is the effect of the size, shape and compliance of one [[ventricle]] on the size, shape and compliance of the other ventricle. These effects are most apparent with respiration or with sudden postural changes. Whereas diastolic ventricular interdependence is mainly mediated through the [[pericardium]], systolic ventricular interdependence is mediated through the interventricular septum as well as through the [[pericardium]]. | [[Ventricle]] interdependence is the effect of the size, shape and compliance of one [[ventricle]] on the size, shape and compliance of the other [[ventricle]]. These effects are most apparent with [[respiration]] or with sudden postural changes. Whereas [[diastolic]] [[ventricular]] interdependence is mainly mediated through the [[pericardium]], [[systolic]] [[ventricular]] interdependence is mediated through the [[interventricular septum]] as well as through the [[pericardium]]. | ||
The clinical importance of ventricular interdependence is in the differentiation between constrictive [[pericarditis]] and restrictive [[myocarditis]] as both of them present with symptoms of right [[heart failure]]. | The clinical importance of [[ventricular]] interdependence is in the differentiation between constrictive [[pericarditis]] and restrictive [[myocarditis]] as both of them present with [[symptoms]] of right [[heart failure]]. | ||
Ventricular interdependence is assessed in the cardiac catheterization laboratory. In this test, the systolic pressure generated in the left ventricle is compared to that in the right ventricle during inspiration. During inspiration, there is negative intrathoracic pressure, and increased filling of the right ventricle. | [[Ventricular]] interdependence is assessed in the [[cardiac catheterization]] [[laboratory]]. In this test, the [[systolic]] [[pressure]] generated in the [[left ventricle]] is compared to that in the [[right ventricle]] during [[inspiration]]. During [[inspiration]], there is negative [[intrathoracic]] [[pressure]], and increased filling of the [[right ventricle]]. | ||
===Constriction=== | ===Constriction=== | ||
Among patients with constrictive pericarditis, with inspiration, there is increased filling of the right ventricle and given that it is constrained by the pericardium, the systolic pressure in the right ventricle rises. There is bulging of the septum into the left ventricle, and reduced filling of the left ventricle, and therefore the pressure drops in the left ventricle. The RV enlarges, and the LV gets smaller during inspiration. | Among [[patients]] with constrictive pericarditis, with [[inspiration]], there is increased filling of the [[right ventricle]] and given that it is constrained by the [[pericardium]], the [[systolic]] [[pressure]] in the [[right ventricle]] rises. There is bulging of the [[septum]] into the [[left ventricle]], and reduced filling of the [[left ventricle]], and therefore the [[pressure]] drops in the [[left ventricle]]. The [[Right ventricle|RV]] enlarges, and the [[Left ventricle|LV]] gets smaller during [[inspiration]]. | ||
Shown below is an image illustrating the changes in the size of the left and right ventricles during respiration in the case of constrictive pericarditis. | Shown below is an image illustrating the changes in the size of the [[Left ventricle|left]] and [[Right ventricle|right ventricles]] during [[respiration]] in the case of constrictive pericarditis. | ||
[[Image:Constriction.png|center|400px|The changes in the size of the left and right ventricles during respiration in the case of constrictive pericarditis.]] | [[Image:Constriction.png|center|400px|The changes in the size of the left and right ventricles during respiration in the case of constrictive pericarditis.]] | ||
===Restriction=== | ===Restriction=== | ||
Among patients with restrictive cardiomyopathy, there is an equal decline in LV and RV systolic pressures during inspiration. | Among [[patients]] with [[restrictive cardiomyopathy]], there is an equal decline in [[LV]] and [[RV]] [[systolic]] [[Pressure|pressures]] during [[inspiration]]. | ||
Shown below is an image illustrating the changes in the size of the left and right ventricles during respiration in the case of restrictive cardiomyopathy. | Shown below is an image illustrating the changes in the size of the [[Left ventricle|left]] and [[Right ventricle|right ventricles]] during [[respiration]] in the case of [[restrictive cardiomyopathy]]. | ||
[[Image:Restriction.png|center|400px|The changes in the size of the left and right ventricles during respiration in the case of restrictive cardiomyopathy.]] | [[Image:Restriction.png|center|400px|The changes in the size of the left and right ventricles during respiration in the case of restrictive cardiomyopathy.]] | ||
==E prime velocity== | ==E prime velocity== | ||
Both syndromes are associated with abnormalities in left ventricular filling. In patients with constriction, this is due to constriction of filling of the left ventricle by the pericardium. In restriction, there is impaired relaxation of the left ventricle. | Both [[syndromes]] are associated with abnormalities in [[left ventricular]] filling. In patients with constriction, this is due to constriction of filling of the [[left ventricle]] by the [[pericardium]]. In [[restriction]], there is impaired [[relaxation]] of the [[left ventricle]]. | ||
===Constriction=== | ===Constriction=== | ||
The E prime velocity is normal as there is no impediment to relaxation of the left ventricle. | The E prime [[velocity]] is normal as there is no impediment to [[relaxation]] of the [[left ventricle]]. | ||
===Restriction=== | ===Restriction=== | ||
The E prime velocity is low (5 or below) in restriction due to impaired filling of the ventricle due to impaired relaxation. | The E prime [[velocity]] is low (5 or below) in [[restriction]] due to impaired filling of the [[ventricle]] due to impaired [[relaxation]]. | ||
==Other Findings Favoring Constriction== | ==Other Findings Favoring Constriction== | ||
*History of [[radiation]], [[breast cancer]], [[Hodgkins disease]], prior [[heart surgery]] | *History of [[radiation]], [[breast cancer]], [[Hodgkins disease]], prior [[heart surgery]] | ||
*When there are signs and symptoms of heart failure out of proportion to myocardial or valve abnormalities | *When there are [[signs]] and [[symptoms]] of [[heart failure]] out of proportion to [[myocardial]] or [[valve]] [[abnormalities]] | ||
*There is respiratory variation on Doppler ultrasound | *There is [[respiratory]] variation on [[Doppler ultrasound]] | ||
*There is septal shift with inspiration | *There is [[septal]] shift with [[inspiration]] | ||
*BNP is not very elevated | *[[BNP]] is not very elevated | ||
*The left atrium is not enlarged | *The [[left atrium]] is not enlarged | ||
==Other Findings Favoring Restriction== | ==Other Findings Favoring Restriction== | ||
*Large or giant atrium due to impaired left ventricular filling. | *Large or giant [[atrium]] due to impaired [[left ventricular]] filling. | ||
==Complete Differential Diagnosis== | ==Complete Differential Diagnosis== | ||
In many cases, | In many cases, constrictive pericarditis is a late sequela of an [[inflammatory]] condition of the [[pericardium]]. The [[inflammatory]] condition is usually an [[infection]] that involves the [[pericardium]], but it may be after a [[myocardial infarction|heart attack]] or after [[coronary artery bypass surgery|heart surgery]]. | ||
Almost half the cases of constrictive pericarditis in the developing world are idiopathic in origin. In regions where [[tuberculosis]] is common, it is the cause in a large portion of cases. | Almost half the cases of constrictive pericarditis in the developing world are [[idiopathic]] in origin. In regions where [[tuberculosis]] is common, it is the cause in a large portion of cases. | ||
Several conditions produce signs and symptoms that are similar to those generated by pericarditis, including life threatening conditions such as myocardial infarction, aortic dissection and pulmonary embolism. | Several conditions produce [[signs]] and [[symptoms]] that are similar to those generated by [[pericarditis]], including life threatening conditions such as [[myocardial infarction]], [[aortic dissection]] and [[pulmonary embolism]]. The conditions with similar [[symptoms]] to constrictive pericarditis include: | ||
The conditions with similar symptoms to constrictive pericarditis include: | |||
:*[[Amyloidosis]] | :*[[Amyloidosis]] | ||
:*Atrial | :*[[Atrial myxoma]] | ||
:*[[Cardiac | :*[[Cardiac cirrhosis]] | ||
:* | :*Primary [[cardiac]] [[neoplasms]] | ||
:* | :*[[Cardiac]] [[sarcoma]] | ||
:*[[Cardiac | :*[[Cardiac tamponade]] | ||
:*[[Dilated cardiomyopathy|Cardiomyopathy, Dilated]] | :*[[Dilated cardiomyopathy|Cardiomyopathy, Dilated]] | ||
:*[[ | :*[[Restrictive Cardiomyopathies|Restrictive Cardiomayopathy]] | ||
:*[[Hemochromatosis]] | :*[[Hemochromatosis]] | ||
:*[[Nephrotic | :*[[Nephrotic syndrome]] | ||
:*[[Ovarian | :*[[Ovarian cancer]] | ||
:*[[Pericardial | :*[[Pericardial effusion]] | ||
:*[[Diseases of the pericardium|Pericarditis, Acute]] | :*[[Diseases of the pericardium|Pericarditis, Acute]] | ||
:*[[Diseases of the pericardium|Pericarditis, Constrictive-Effusive]] | :*[[Diseases of the pericardium|Pericarditis, Constrictive-Effusive]] | ||
:*[[Uremic pericarditis|Pericarditis, Uremic]] | :*[[Uremic pericarditis|Pericarditis, Uremic]] | ||
:*[[Sarcoidosis]] | :*[[Sarcoidosis]] | ||
:*[[Superior | :*[[Superior vena cava syndrome]] | ||
:*[[Tricuspid | :*[[Tricuspid regurgitation]] | ||
:*[[Tricuspid | :*[[Tricuspid stenosis]] | ||
:*[[Uremia]] | :*[[Uremia]] | ||
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[[nl:Pericarditis constrictiva]] | [[nl:Pericarditis constrictiva]] | ||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Emergency medicine]] | |||
[[Category:Intensive care medicine]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Up-To-Date cardiology]] | |||
[[Category:Board review]] | [[Category:Board review]] | ||
Latest revision as of 18:18, 27 December 2019
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Constrictive Pericarditis Microchapters |
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Differentiating Constrictive Pericarditis from other Diseases |
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Treatment |
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Case Studies |
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Constrictive pericarditis differential diagnosis On the Web |
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American Roentgen Ray Society Images of Constrictive pericarditis differential diagnosis |
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Constrictive pericarditis differential diagnosis in the news |
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Risk calculators and risk factors for Constrictive pericarditis differential diagnosis |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Huda A. Karman, M.D.
Overview
Constrictive pericarditis must be differentiated from restrictive cardiomyopathy. The evaluation of ventricular interdependence between the two ventricles is the best objective method to distinguish the two syndromes. Constrictive pericarditis should also be differentiated from cardiac tamponade, right-sided atrial tumors, such as myxomas, superior vena cava syndrome, right-sided valvular abnormalities (tricuspid stenosis or tricuspid regurgitation), systolic or diastolic congestive heart failure( pressure-overload and myocardial, valvular, or atherosclerotic disease causes)
Pathophysiology
Both syndromes are associated with abnormalities in left ventricular filling. In patients with constriction, this is due to constriction of filling of the left ventricle by the pericardium. In restriction, there is impaired relaxation of the left ventricle.
Ventricular Interdependence
Ventricle interdependence is the effect of the size, shape and compliance of one ventricle on the size, shape and compliance of the other ventricle. These effects are most apparent with respiration or with sudden postural changes. Whereas diastolic ventricular interdependence is mainly mediated through the pericardium, systolic ventricular interdependence is mediated through the interventricular septum as well as through the pericardium.
The clinical importance of ventricular interdependence is in the differentiation between constrictive pericarditis and restrictive myocarditis as both of them present with symptoms of right heart failure.
Ventricular interdependence is assessed in the cardiac catheterization laboratory. In this test, the systolic pressure generated in the left ventricle is compared to that in the right ventricle during inspiration. During inspiration, there is negative intrathoracic pressure, and increased filling of the right ventricle.
Constriction
Among patients with constrictive pericarditis, with inspiration, there is increased filling of the right ventricle and given that it is constrained by the pericardium, the systolic pressure in the right ventricle rises. There is bulging of the septum into the left ventricle, and reduced filling of the left ventricle, and therefore the pressure drops in the left ventricle. The RV enlarges, and the LV gets smaller during inspiration.
Shown below is an image illustrating the changes in the size of the left and right ventricles during respiration in the case of constrictive pericarditis.
Restriction
Among patients with restrictive cardiomyopathy, there is an equal decline in LV and RV systolic pressures during inspiration.
Shown below is an image illustrating the changes in the size of the left and right ventricles during respiration in the case of restrictive cardiomyopathy.
E prime velocity
Both syndromes are associated with abnormalities in left ventricular filling. In patients with constriction, this is due to constriction of filling of the left ventricle by the pericardium. In restriction, there is impaired relaxation of the left ventricle.
Constriction
The E prime velocity is normal as there is no impediment to relaxation of the left ventricle.
Restriction
The E prime velocity is low (5 or below) in restriction due to impaired filling of the ventricle due to impaired relaxation.
Other Findings Favoring Constriction
- History of radiation, breast cancer, Hodgkins disease, prior heart surgery
- When there are signs and symptoms of heart failure out of proportion to myocardial or valve abnormalities
- There is respiratory variation on Doppler ultrasound
- There is septal shift with inspiration
- BNP is not very elevated
- The left atrium is not enlarged
Other Findings Favoring Restriction
- Large or giant atrium due to impaired left ventricular filling.
Complete Differential Diagnosis
In many cases, constrictive pericarditis is a late sequela of an inflammatory condition of the pericardium. The inflammatory condition is usually an infection that involves the pericardium, but it may be after a heart attack or after heart surgery.
Almost half the cases of constrictive pericarditis in the developing world are idiopathic in origin. In regions where tuberculosis is common, it is the cause in a large portion of cases.
Several conditions produce signs and symptoms that are similar to those generated by pericarditis, including life threatening conditions such as myocardial infarction, aortic dissection and pulmonary embolism. The conditions with similar symptoms to constrictive pericarditis include:
- Amyloidosis
- Atrial myxoma
- Cardiac cirrhosis
- Primary cardiac neoplasms
- Cardiac sarcoma
- Cardiac tamponade
- Cardiomyopathy, Dilated
- Restrictive Cardiomayopathy
- Hemochromatosis
- Nephrotic syndrome
- Ovarian cancer
- Pericardial effusion
- Pericarditis, Acute
- Pericarditis, Constrictive-Effusive
- Pericarditis, Uremic
- Sarcoidosis
- Superior vena cava syndrome
- Tricuspid regurgitation
- Tricuspid stenosis
- Uremia
References