Examine this patient's cardiovascular system.



· Dyspnoea.

· Fatigue.

· Ankle or abdominal swelling.

· Nausea, vomiting, dizziness and cough.


· The patient may appear cachectic.

· Pulse may be regular or irregularly irregular (one third have atrial fibrillation).

· Prominent x and y descents in the jugular venous pulse, and the level of the JVP

may rise with inspiration (Kussmaul's sign).

· Apex beat is not palpable.

· Early diastolic pericardial knock along the left sternal border, which may be accentuated by


· Lungs are clear but there may be pleural effusion.

· Markedly distended abdomen with hepatomegaly and ascites.

· Pitting leg oedema.


This patient has constrictive pericarditis (lesion) caused by radiation therapy for previous Hodgkin's

disease (aetiology) and is now limited by dyspnoea and marked ascites (functional status).


Mention some causes of constrictive pericarditis.

· Tuberculosis (<15% of patients).

· Connective tissue disorder.

· Neoplastic infiltration.

· Radiation therapy (often years earlier).

· Postpurulent pericariditis.

· Haemopericardium after surgery (rare).

· Chronic renal failure.


What is the mechanism for pericardial knock?

It is caused by the abrupt halting of rapid ventricular filling.

Mention the differential diagnosis of the early diastolic sound.

· Loud P2 (see p. 103).

· S3 gallop (see p. 39).

· Opening snap (mitral stenosis).

· Pericardial sound.

· Tumour plop (atrial myxoma).

What is Beck's triad?

The presence of low arterial blood pressure, high venous pressure and absent apex

in cardiac tamponade is known as Beck's triad.

How would you investigate a patient with constrictive pericarditis?

· Chest radiograph typically shows normal heart size and pericardial calcification (note: the combination

of pulsus paradoxus, pericardial knock and pericardial calcification favours the diagnosis of

constrictive pericarditis).

· ECG shows low voltage complexes, non-specific T wave flattening or atrial fibrillation.

· Echocardiogram shows myocardial thickness is normal and may reveal thickened pericardium;

normal ventricular dimensions with enlarged atria and good systolic and poor diastolic dysfunction.

Doppler shows increased right ventricular systolic and decreased left ventricular systolic velocity with

inspiration, expiratory aug-mentation of hepatic vein diastolic flow reversal.

· CT scan or MRI: shows normal myocardial thickness usually, and pericardial thickening and


· Cardiac catheterization typically shows identical left and right ventricular filling pressures and

pulmonary artery systolic pressure usually <45 mmHg, with normal myocardial biopsy.

Haemodynamic tracings show rapid 'y' descent in atrial pressure and early dip in diastolic pressure,

with pressure rise to plateau in mid or late diastole.

How would you treat a patient with constrictive pericarditis?

· Surgery is the only satisfactory treatment: Complete surgical resection of the pericardium (myocardial

inflammation or fibrosis may delay symptomatic response).

Patients with tuberculous pericarditis should be pre-treated with antituberculosis therapy; if the

diagnosis is confirmed after pericardial resection, full anti-tuberculous therapy should be continued for

6-12 months after resection.

C.S. Beck (1894-1971), surgeon, Peter Bent Brigham Hospital in Boston.

W. Broadbent(1868-1951), English physician who qualified from St Mary's Hospital Medical School,

London. He described the Broadbent sign in constrictive pericarditis, which is an indrawing of the 11th

and 12th left ribs with a narrowing and retraction of the intercostal space posteriorly; this occurs as a

result of pericardial adhesions to the diaphragm.