Review Question - QID 214399

This patient is presenting after a viral illness with dyspnea, hypotension, tachycardia, jugular venous distension, lower extremity edema, and an ultrasound demonstrating a normal ejection fraction with reduced ventricular filling, which are concerning for constrictive pericarditis.

Constrictive pericarditis is the result of scarring and loss of the normal elasticity of the pericardial sac and can occur secondary to many etiologies including infection (such as a viral infection or tuberculosis), post-cardiac surgery, post-radiation, connective tissues disorders, certain malignancies, uremia, and spontaneously. The restrictive pericardium leads to impairment of ventricular filling in diastole. As a result, the majority of ventricular filling occurs rapidly in early diastole, and the ventricular volume does not increase after the early filling period. Constrictive pericarditis and restrictive cardiomyopathy both lead to diastolic heart failure with normal systolic function, and abnormal ventricular filling that subsequently leads to a similar presentation. If there is not a clear etiology of the patient's symptoms, a biopsy can be performed to confirm the diagnosis, which may be necessary as the management of constrictive pericarditis and restrictive cardiomyopathy are rather different. Patients with constrictive pericarditis will present with hypotension, tachycardia, a pericardial friction rub/knock, Kussmaul sign, and impaired diastolic filling on ultrasound. Constrictive pericarditis is typically treated with a pericardiectomy.

Incorrect Answers:
Answer 1: Cardiac tamponade presents with muffled heart sounds, electrical alternans on ECG, jugular venous distension, hypotension, and tachycardia. Ultrasound will demonstrate an echogenic rim of fluid surrounding the heart, and management involves stabilization with pericardiocentesis followed by placement of a pericardial drain or window.

Answer 3: Heart failure presents in older patients with comorbidities such as diabetes and atherosclerotic disease and presents with dyspnea, pulmonary crackles, pulmonary edema (on radiography), jugular venous distension, and pitting lower extremity edema. It would be unlikely in this young and otherwise healthy patient.

Answer 4: Myocarditis presents after a viral infection with a fever, chest pain, shortness of breath, non-specific ECG changes (such as ST-segment changes or T-wave inversion) and elevated troponins. The management of this condition is supportive in nature, and there is a high mortality.

Answer 5: Restrictive cardiomyopathy differs from constrictive pericarditis in that this is a condition/disease of the myocardium. The myocardium (rather than the pericardial sac) does not fill, and this can be caused by conditions such as sarcoidosis, amyloidosis, hemochromatosis, malignancy, and fibrosis. Management involves treating the underlying cause.

Bullet Summary:
Constrictive pericarditis can occur after a viral infection and presents with edema, jugular venous distension, impaired cardiac function, Kussmaul sign, and a pericardial knock.