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features distinguishing constrictive pericarditis

Differential diagnsosis: 1) constrictive pericarditis a) signs/symptoms - pulsus paradoxus generally absent - jugular venous distension - prominent x & y descent* - wave form does not fall, but may increase with inspiration (Kussmaul's sign)* - 3rd heart sound generally absent - pericardial knock often present difficult to distinguish from 3rd heart sound b) laboratory - serum BNP: mean value 130 pg/mL* c) electrocardiogram - ECG voltage may be low - no electrical alternans - no distinguishing features from restrictive cardiomyopathy d) echocardiogram - thickened pericardium - pericardial calcifications often present* - no pericardial effusion - right ventricular size generally normal - myocardial thickness generally normal* - no right atrial & right ventricular diastolic collapse - early mitral flow velocity increased - exaggerated respiratory variation in flow velocity* e) computed tomography (CT)/magnetic resonance imaging (MRI) - thickened calcific pericardium* f) cardiac catheterization - equalization* of diastolic pressures generally present g) biopsy not helpful 2) restrictive cardiomyopathy a) signs/symptoms - pulsus paradoxus is rare - jugular vein - prominent y descent is rare* - prominent x descent is generally present - Kussmaul's sign is absent* - 3rd heart sound is rare - no pericardial knock b) laboratory - serum BNP: mean value > 800 pg/mL* c) electrocardiogram - ECG voltage may be low - no electrical alternans - no distinguishing features from constrictive pericarditis d) echocardiogram - no thickened pericardium - no pericardial calcifications - no pericardial effusion - right ventricular size generally normal - myocardial thickness generally increased* - no right atrial & right ventricular diastolic collapse - early mitral flow velocity increased - normal respiratory variation in flow velocity* e) computed tomography (CT)/magnetic resonance imaging (MRI) - no thickened calcific pericardium* 6) cardiac catheterization - no equalization of diastolic pressures in all 4 cardiac chambers* f) biopsy may be helpful* 3) pericardial tamponade a) signs/symptoms - pulsus paradoxus is common - jugular vein - no prominent y descent - prominent x descent - Kussmaul's sign is absent - 3rd heart sound is absent - no pericardial knock b) electrocardiogram - ECG voltage may be low - electrical alternans may be present c) echocardiogram - no thickened pericardium - no pericardial calcifications - pericardial effusion - right ventricular size generally small - myocardial thickness generally normal - right atrial & right ventricular diastolic collapse - early mitral flow velocity normal - exaggerated respiratory variation in flow velocity d) computed tomography (CT)/magnetic resonance imaging (MRI) - no thickened calcific pericardium e) cardiac catheterization - equalization of diastolic pressures in all 4 cardiac chambers generally present f) biopsy not helpful 4) right ventricular myocardial infarction a) signs/symptoms - pulsus paradoxus is rare - jugular vein - prominent y descent is rare - prominent x descent is rare - Kussmaul's sign is absent - 3rd heart sound may be present - no pericardial knock b) electrocardiogram - ECG voltage is normal - no electrical alternans c) echocardiogram - no thickened pericardium - no pericardial calcifications - no pericardial effusion - enlarged right ventricular size - normal myocardial thickness - no right atrial & right ventricular diastolic collapse - early mitral flow velocity may be increased - normal respiratory variation in flow velocity d) computed tomography (CT)/magnetic resonance imaging (MRI) - no thickened calcific pericardium e) cardiac catheterization - equalization* of diastolic pressures is variable f) biopsy not helpful * distinguishing features of restrictive cardiomyopathy & constrictive pericarditis

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constrictive pericarditis

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1097
  2. Medical Knowledge Self Assessment Program (MKSAP) 15, 19 American College of Physicians, Philadelphia 2009, 2022