In 1956, Dressier described a syndrome occurring in the first few days to several weeks following myocardial infarction which involved fever, pericarditis, and pleuritis. The incidence of this post-myocardial infarction syndrome is 6-25%. Autopsy studies have shown that it is very common to have a localized area of pericarditis overlying the area of infarcted myocardium. Typically, patients with Dressler’s syndrome have a low-grade fever and a pericardial friction rub. When the pain is severe, a short course of high-dose aspirin will usually relieve the pain within 48 hours.
1Describe the physical findings of constrictive pericarditis.
The neck is the starting point as the jugular venous pattern is the most important part of the examination in this condition.
Jugular veins: The jugular veins are distended with prominent X and Y descents. There is usually an increase in the height of the jugular venous pulsation with inspiration (Kussmaul’s sign).
Lungs: The lung fields are usually clear. Sometimes, a pleural effusion may be present and can be a clue to pericardial constriction in patients being evaluated for isolated pleural effusion of unknown etiology.
Heart: The apical impulse is usually soft and diffuse. S[ and S2 may be decreased in intensity. A diastolic pericardial knock may be heard along the left sternal border. The pericardial knock is a loud sound occurring early in diastole (0.09-0.12 seconds after A2) and sometimes accentuated with inspiration. Pericardial knocks may be confused with an S3 but may be distinguished by a higher acoustic frequency and earlier occurrence than an S3.
Abdomen: There may be distention from ascites. The liver is enlarged and pulsatile. In chronic cases, the spleen may also be enlarged.
Extremities: Peripheral edema is present.
How is the diagnosis of constrictive pericarditis made in the cardiac catheterization laboratory?
Arterial and central venous (usually femoral) catheters are placed so that the right and left heart pressures can be measured and recorded simultaneously. When constriction is present, both right and left ventricular diastolic pressures are elevated and virtually identical (5 mmHg in difference). The right atrial pressure waveform has steep X and Y descents and may show Kussmaul’s sign, i.e., rise during inspiration. The right and left ventricular pressure curves may show the classic square root sign,‚ which represents an early diastolic dip in pressure followed by a plateau. The plateau occurs because the constricting pericardium abruptly limits ventricular filling. The characteristic dip and plateau may be difficult or impossible to see during tachycardia. Restrictive cardiomyopathies may have many of the same hemodynamic findings as constrictive pericarditis, and the distinction between the two processes can sometimes be difficult.
How does tuberculous pericarditis present clinically?
Although tuberculosis has become less common in industrialized nations in the last 30 years, it is still seen in patients from developing countries such as Africa and Asia and in association with the acquired immunodeficiency syndrome (AIDS). The incidence of tuberculous pericarditis in patients with pulmonary tuberculosis has ranged from 1-8% in several studies. Common physical findings are fever, pericardial rub, and hepatomegaly. Pulmonary infiltrates have been present in 32-72% of patients in different studies. Tuberculin skin testing is usually positive unless the patient has skin test anergy. Tubercle bacilli are often not found on stained smears of pericardial fluid. Therefore, pericardial biopsy in addition to pericardiocentesis provides a higher probability of definitive diagnosis.