Constrictive pericarditis: Causes, by stage of symptoms, treatment

Author: Strokina OA, therapist, doctor of functional diagnostics.
September 2019.

ICD-10 code: I31.1.

Constrictive pericarditis - compression of the heart pliable pericardium (outer lining of the heart). Symptoms include fatigue, feeling short of breath, swelling in the legs, abdominal distension, reducing the difference between the systolic and diastolic pressures. Diagnosis is based on imaging techniques pericardium: Echo-KS, MRI, CT. Laboratory tests are needed to identify the causes of constrictive pericarditis. Only complication is treated by surgery, but possible, and support drug (aspirin, NSAIDs, colchicine, diuretics and others) to conduct surgery when it is impossible.

Constrictive pericarditis - a serious complication of acute fibrinous, seroplastic and chronic exudative pericarditis. When its development occurs by compression of the pericardium of the heart due to the proliferation of it coarse scar tissue. It limits the natural movement of the heart in the pericardial cavity, preventing the filling of the ventricles with blood, leading to symptoms similar to cardiac tamponade.

Causes and risk factors

The risk of progression of pericardial constriction in much depends on the cause of the disease. The risk of developing high constriction, about 20-30%, in bacterial, especially purulent inflammation of the pericardium.

Constrictive pericarditis rarely occurs when the following pericarditis:

• viral;
• idiopathic;
• neoplastic (tumor nature);
• immune-mediated.

Risk factors

Risk factors also include certain categories of people:

• HIV-infected;
• TB patients;
• have suffered chest injuries;
• cardiac surgery;
• passing radiation therapy in the chest area.

Symptoms of constrictive pericarditis

Clinic constrictive pericarditis may develop months or even years, and it is associated with impaired blood supply to the heart ventricles due to the gradual compression of them. Most quickly begins to suffer right ventricle to the stagnation of the development of the systemic circulation. Then to the clinic joins left ventricular failure (shortness of breath, dyspnea, cough) and other failure of internal organs, especially the liver.

Patients with diagnosed "constrictive pericarditis" complain:

• fatigue;
• peripheral edema (for legs, arms);
• lack of air;
• bloating;
• loss of appetite;
• swelling of the neck veins;
• reduction in pulse pressure - the difference between systolic and diastolic blood pressure;
• paradoxical pulse (decrease in systolic blood pressure by more than 10% during quiet breathing inspiration) in 30% of cases.

Some of these symptoms indicate stagnation of blood in the systemic circulation due to the development of right ventricular failure - ascites (fluid in the abdominal cavity) accumulation in the pleural exudate, increased liver size, venous stasis in the veins of the lower limbs.

stage of the disease

The process of constrictive pericarditis has several stages:

Hidden:

• It characterized by a long passage, perhaps for several years.
• Symptoms are often absent or poorly expressed so that people do not even pay attention to them.
• Stage of development is reversible with time begun treatment.

Initial stage:

• Manifested clinic hemodynamic instability: more pronounced weakness, shortness of breath aggravated by exertion.
• On examination revealed edema and pallor, jugular venous distention, increased heart rate (heart rate).
• There may be enlargement of the liver due to the stagnation of blood in it, due to abdominal ascites (fluid in the abdominal cavity).
• It is also possible to recover from constrictive pericarditis in this stage surgically.

The active phase:

• Characterized by the same symptoms, but in a much more severe form.
• Due to the rise of right heart failure increases venous congestion of the systemic circulation: It appears bluish tint in the face, lower extremity edema, ascites (fluid in the abdominal cavity) increases volume.
• Surgical treatments are still effective at that stage.

dystrophic:

• The final stage of constrictive pericarditis.
• Since constrictive pericarditis results in poor functioning of the right ventricle, there is stagnation of blood on the systemic circulation. Blood is collected not only in the veins of the extremities, but also in other organs. Most suffer liver. From stage to stage its function is increasingly violated. As a result of developing clinical hepatic failure with pronounced asthenic syndrome (Exhaustion, a feeling of fatigue, weakness), decreased blood albumin swelling of the upper and lower limbs. Also, there is atrial fibrillation patients.
• Surgical treatment of dystrophic step constrictive pericarditis not shown, since it is associated with high risk of death.

There are also several specific forms of constrictive pericarditis:

• Transient option - a temporary form of constriction develops simultaneously with pericarditis and a small effusion. Usually it occurs on the type of acute inflammatory pericarditis.
• Exudative-constrictive. Patients with pericardial konstritsiey usually completely filled with scar tissue. But sometimes formed, and areas with effusion. In this situation, not only fused pericardial heart squeezes. but also areas with effusion, causing symptoms similar to symptoms of cardiac tamponade.
• Chronic constrictive pericarditis is characterized by the absence of pericardial effusion and manifests symptomatic heart failure: fatigue, shortness of breath appear already at mild exertion and at rest.

survey

instrumental methods

To identify constrictive pericarditis instrumental diagnostic methods are essential:

Electrocardiogram:

• Reduction wave amplitude, atrial fibrillation, (now atrial fibrillation), blockades, infarktopodobnye rarely changes.

echocardiography:

• In the two-dimensional mode determined by thickening and calcification deposits in the pericardium, indirect signs of constriction:
  • increased atrial size at normal ventricles,
  • abnormal movement of the interventricular septum,
  • no increase in the left ventricle when filled with blood,
  • expansion of the inferior vena cava and hepatic veins.
• When the Doppler scan is determined by reduction of ventricular filling and a multi-speed flow through the mitral and tricuspid valves.

Computer and magnetic resonance imaging:

• The thickness of the pericardium is greater than 3 mm, the presence of calcifications (detected on CT).

analyzes

Laboratory diagnosis methods allow to identify the possible cause of pericarditis, which led to the constriction. are required here:

General blood analysis:

• likely leukocytosis (Increase leukocyte content), increased ESR (erythrocyte sedimentation rate), The appearance of young forms of leukocytes.
• In addition, some percentages of leukocytes forms say about bacterial, viral disease that may narrow down the list of causes of disease.

Blood chemistry:

• Elevated CRP (C-reactive protein) Speaks of active inflammation,
• Troponin and CK-MB - cardiac enzymes, increase which indicates what is happening within the process infarction (heart attack, inflammation)
• creatinine and urea (elevated in renal failure - uremic pericarditis),
• ALT, AST, bilirubin (Liver disease markers show stage heart failure. elevated in advanced cases).
• General urine analysis - can judge infection and other pathological kidney (uremic pericarditis embodiment).

When the doctor realized of inspection, survey, test results, in which direction to conduct a diagnostic search for the causes of the disease, he shall designate a specific examination methods:

• intradermal tuberculin test (Mantoux test, Diaskintest);
• blood cultures in suspected infective endocarditis;
• virological testing by ELISA and PCR;
• HIV testing, Haemophilus influenzae;
• exception Chlamydia and Mycoplasma infections by ELISA and PCR;
• definition antinuclear factor, rheumatoid factor, Antibodies to cardiolipin (in systemic lupus erythematosus, rheumatoid arthritis and others);
• titer antistreptolysin-O (Rheumatism);
• determination of antibody titers to miolemme and serum actomyosin (perimiokardialny suspected tuberculosis);
• determine the level of thyroid hormone (hypothyroidism).

Treatment of constrictive pericarditis

Despite the fact that the mainstay of therapy constrictive pericarditis are surgical methods, conservative treatment is also able to influence its course.

drug therapy

Causal treatment referral identified causes of the disease, helping to prevent recurrences. As an example resembles tuberculous pericarditis. Antibacterial drugs aimed at combating tuberculosis bacteria, can reduce the risk of constriction from 80% to 10%.

Resolution transient constriction of options when it "cured", but a few months later, she returned. For such purpose are usually standard anti-inflammatory therapy - aspirin or NSAIDs (nonsteroidal anti-inflammatory drugs - indomethacin, ibuprofen).

Supportive drug therapy (mostly diuretics) to reduce congestion signs in cases, the inability to use surgical techniques - contraindications or high risk operations.

Surgery

Speaking about the surgical treatment of constrictive pericarditis, it is worth mentioning that there are several of its specific forms, which mean different tactics of patients:

Transient option is treated anti-inflammatory drugs, are permitted in a few weeks. Constriction occurs because of inflammation of the pericardial leaflets to their thickening. Accordingly, when the inflammation runs, passes and constriction. Therefore, in the absence of data on the course of chronic patient with newly diagnosed constrictive pericarditis we recommend that you spend 2-3 weeks of conservative therapy before resorting to surgical methods.

Exudative-constrictive pericarditis treated with perikardektomii (excision), visceral (near the heart) sheet.

Chronic constrictive pericarditis is treated only perikardektomiey. Refers to an operation is necessary to very carefully, particularly in patients with end-stage development of constriction. Since the surgery itself is not greatly improve their quality of life and the risk of death is very high and is 6-12%.

Forecast

Constrictive pericarditis - a very serious complication with a rather unfavorable prognosis, which is only getting worse with time course of the disease. Perikardektomiya - the only treatment of this disease, however, and it does not guarantee a cure. The disappearance of symptoms is observed only in 60% of patients. And in extreme cases even able to complete perikardektomiya only temporarily improve the patient's condition.

Constrictive pericarditis is one of those diseases that are best avoided. It is essential in time, at the initial stage, when the first symptoms (fatigue, shortness of breath, puffiness of the feet) to consult a doctor. Only he in person will be able to properly diagnose and prescribe the correct treatment that is likely to prevent the development of constriction.