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• How to mitigate diagnostic delay in constrictive pericarditis
  oscar,m jolobe
  Published on: 15 January 2019

• Published on: 15 January 2019

  How to mitigate diagnostic delay in constrictive pericarditis

  • oscar,m jolobe, retired geriatrician manchester medical society

  Given the fact that constrictive pericarditis is an eminently reversible cause of congestive heart failure(CHF) its timely clinical recognition deserved special mention in the recent review of epidemiology of pericardial diseases in Africa(1). Timely recognition and treatment might, arguably, mitigate the risk of perioperative mortality which is currently of the order of 12.5% to 14%, given the fact that this adverse statistic is principally generated by patients who come to operation in New York Heart Association functional class III and IV(2)(3). Accordingly, what needs to be done is to educate doctors and medical students to identify stigmata which differentiate CP from "run of the mill" CHF so as to expedite early referral of suspected CP to tertiary centres for definitive diagnosis and, hence, timely pericardiectomy.
  According to Little and Freeman, in the typical case of CP, "there will be marked jugular venous distension, hepatic congestion, ascites, and peripheral oedema, while the lungs remain clear"(3). Consequently, on the basis of their series of 30 patients, Evans and Jackson observed that "the presence of distended neck veins in a patient who is able to lie comfortably in the recumbent posture is characteristic of the disease"(4). The jugular venous pressure(JVP) response to a diagnostic trial of diuretic therapy may also be of diagnostic significance(5)(6). In CP, the typical response is that the JVP remains persisten...

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  Given the fact that constrictive pericarditis is an eminently reversible cause of congestive heart failure(CHF) its timely clinical recognition deserved special mention in the recent review of epidemiology of pericardial diseases in Africa(1). Timely recognition and treatment might, arguably, mitigate the risk of perioperative mortality which is currently of the order of 12.5% to 14%, given the fact that this adverse statistic is principally generated by patients who come to operation in New York Heart Association functional class III and IV(2)(3). Accordingly, what needs to be done is to educate doctors and medical students to identify stigmata which differentiate CP from "run of the mill" CHF so as to expedite early referral of suspected CP to tertiary centres for definitive diagnosis and, hence, timely pericardiectomy.
  According to Little and Freeman, in the typical case of CP, "there will be marked jugular venous distension, hepatic congestion, ascites, and peripheral oedema, while the lungs remain clear"(3). Consequently, on the basis of their series of 30 patients, Evans and Jackson observed that "the presence of distended neck veins in a patient who is able to lie comfortably in the recumbent posture is characteristic of the disease"(4). The jugular venous pressure(JVP) response to a diagnostic trial of diuretic therapy may also be of diagnostic significance(5)(6). In CP, the typical response is that the JVP remains persistently in spite of resolution of peripheral oedema(5)(6), even when this is accompanied by weight loss(5). At the very least, patients who exhibit those stigmata should have chest x-ray to detect pericardial calcification. If the index of suspicion for CP still persists, the next step should be computed tomography of the thorax to detect pericardial thickening.
  In developed countries delay in the clinical recognition of CP is common(7), but this diagnostic lapse can be excused on the basis of the rarity of CP in those societies. In the African context, however, where CP is more prevalent, preventable diagnostic delay is inexcusable.
  I have no conflict of interest and no funding
  References
  (1) Noubiap JJ., Agbor VN., Ndoadoumgue AL et al
  Epidemiology of pericardial disease in Africa: A sytematic review
  Heart 10th November 2018;Doi 10.1136/heartjnl2018-313922
  (2) Yangni-Angate K., Tanauh Y., Meneas C et al
  Surgical experience on chronic constricitve pericarditis in African setting: review of 35 years experience in Cote d'Ivorie
  Cardiovasc Diagn Ther 2016,6(Suppl 1):S13-S19
  (3)Mutyaba AK., Balkaran S., Cloete R et al
  Constrictive pericarditis requiring pericardiectomy at Groote Schuur Hospital Capetown, South Africa: Cuases and perioperative outcomes in the HIV era(1990-2012)
  The Journal of Thoracic and Cardiovascular surgery 2014;148:3058-3065
  (3)Little WC., Freeman GL
  Pericardial disease
  Circulation 2006;113:1622-1632
  (4) Evans W., Jackson F
  Constrictive pericarditis
  British Heart Journal 1952:14:53-69
  (5)Conti CR., Friesinger GC
  Chronic constrictive pericarditis; clinical and laboratory findings in 11 case
  Johns Hopkins Med J 1967;120:262-274
  (6) Chambliss JR., Jaruszewski EJ., Brofman BL., Martin JF., Feil H
  Chronic cardiac compression(Chronic constrictive pericarditis)
  A critical study of sixty one operated cases with follow up
  Circulation 1951;4:816-835
  (7) Marshall A., Ring N., Lewis T
  Constrictive pericarditis: lessons from the past five years experience in the South West Cardiothoracic centre
  Clinical Medicine 2006;6:592-597

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  Conflict of Interest:
  None declared.

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