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5. Constrictive pericarditis

All are causes of clinical heart failure. However, most of the other causes are associated with an enlarged heart or enlarged ventricular wall thickness, abnormal systolic function or an elevated NT-pro BNP (5).

Constrictive cardiomyopathy is a disorder where cardiac filling is impeded by a pericardium that is unable to expand sufficiently to adequately fill the ventricular chambers during diastole. The lack of filling results in reduced cardiac output. The percent of the ventricle emptied during systole, the ejection fraction, is normal. An important pathophysiologic feature of constrictive pericarditis is greatly enhanced ventricular interdependence and a dissociation of intracardiac and intrathoracic pressures. Symptoms may be related to fluid overload (edema, anasarca) or to diminished cardiac output (fatigability, dyspnea on exertion). Findings on physical examination include elevated jugular venous pressure (JVP), pulsus paradoxus (an exaggerated drop in systemic blood pressure greater than 10 mmHg during inspiration) and Kussmaul's sign (the lack of an inspiratory decline in JVP).

BNP is released from the atrium in response to the dilatation that occurs in most forms of heart failure. However, with constrictive pericarditis the atrium is not dilated explaining the relatively low NT-pro BNP levels (5).

The restrictive cardiomyopathies have pathophysiology similar to constrictive pericarditis. Both constrictive pericarditis and restrictive cardiomyopathy limit diastolic filling and result in diastolic heart failure, with relatively preserved global systolic function. However, in restrictive cardiomyopathies the etiology is an inability of the heart muscle to adequately stretch while in constrictive pericarditis it is an inability of the pericardium to stretch. Restrictive cardiomyopathies are often secondary to a systemic disorder such as amyloidosis, sarcoidosis, scleroderma, hemochromatosis, eosinophilic heart disease, or as a result of radiation treatment.

Which of the following is true regarding constrictive pericarditis and restrictive cardiomyopathy?

1. Pericardial calcification in a patient with heart failure suggest constrictive pericarditis
2. Cardiac magnetic resonance imaging (CMR) is the best test to separate restrictive cardiomyopathy from constrictive pericarditis
3. Constrictive pericarditis usually responds to medical or surgical therapy
4. Restrictive cardiomyopathy requires medical therapy for the heart failure and may require heart transplantation
5. All of the above

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