**5.3 Diagnostics**

*Inflammatory Heart Diseases*

Recurrent viral or idiopathic pericarditis is typically managed with an outpatient medical regimen [2, 52, 54] initially consisting of an NSAIDs and colchicine [15] as glucocorticoids are known to increase the risk of recurrence despite multiple recurrences of pericarditis [56]. Glucocorticoid therapy is, therefore, reserved for patients who are either unable to tolerate NSAIDs or have failed NSAIDs therapy in

It is important to ensure an adequate trial of NSAIDs was given prior to labeling a patient as refractory. Common agents such as Aspirin and Ibuprofen should be attempted first followed by Indomethacin for treatment resistant cases. Medication should be administered in three doses over 24 hours to ensure consistent therapeutic levels, and dosage should be titrated up as needed to achieve symptom control until the daily maximum is reached or symptoms have subsided [10, 32, 39, 52, 54, 57]. Patients with recurrent pericarditis are often times designated as refractory to colchicine therapy after having received inappropriate dosing or rapid tapers [43]. In addition, colchicine should be given twice a day in order to reduce the risk of

In cases of recurrent pericarditis refractory to treatment with NSAIDs, colchicine, and glucocorticoids, patients found to have the evidence of systemic inflammation may benefit from anti-interleukin-1 therapy. A recent trial in 2016 demonstrated a significant reduction of recurrence (90–18%) in patients with pericarditis resistant to colchicine and dependent on corticosteroids with the addition of anakinra, an IL-1B antagonist [59]. Although promising, this study's results were limited by a small sample size and inconsistent colchicine dosing across trial

Constrictive pericarditis is a condition that occurs when a thickened or calcified pericardium loses elasticity resulting in the reduction of diastolic filling. It is a syndrome that is the end result of chronic pericarditis and pericardial effusion gradually progressing to fibrosis [2, 15, 29, 60]. Such impairment overtime causes the reduction of pericardial space, which in turn uncouples intrathoracic and intracardiac pressures generating increased interventricular interdependence visible on

Constrictive pericarditis can occur as a result of inflammation and effusion from any pericardial disease [2, 31, 63]. A combination of studies has found that 42 to 61% of cases were idiopathic or viral, 11 to 37% postcardiac surgery, 2 to 31% postradiation, 3 to 7% due to connective tissue disorders, 3 to 15% bacterial or tuberculous, and 1 to 10% related to malignancy, trauma, drug toxicity, sarcoidosis, or uremic pericarditis [64–69]. Tuberculosis remains a major global cause of

Patients with constrictive pericarditis usually present with symptoms of right heart failure in the absence of ventricular function impairment. Symptoms are consistent with volume overload, such as edema, pleural effusion, dyspnea, ascites,

constrictive pericarditis especially in endemic nations [2, 70].

poor compliance due to gastrointestinal discomfort [10, 57, 58].

participants warranting further investigation.

**5. Constrictive pericarditis**

echocardiogram [2, 35, 61, 62].

**5.2 Clinical presentation**

**5.1 Etiology**

**4.4 Treatment**

the past [2].

**20**

Although the diagnosis of constrictive pericarditis can be made by echocardiography [72], an ECG and chest X-ray should also be obtained as part of the initial evaluation. There are no specific ECG changes consistently indicative of constrictive pericarditis; however, an ECG may be helpful in ruling out other cardiac pathology. The chest X-ray may show the evidence of pericardial calcification in which the presence of right heart failure would be strongly suggestive of constrictive pericarditis; however, the absence of such a finding would not rule out the disease [2].

All patients with suspected pericardial disease should be evaluated with echocardiography [2, 73]. Septal bounce and pericardial thickening on M-mode and 2-dimensional echocardiography would be suggestive of a constrictive pattern. On Doppler echocardiography, increased interventricular interdependence is associated with pericardial fibrosis, and the ratio of the right ventricular (RV) area to the left ventricular (LV) area, known as systolic area index (SAI), is virtually diagnostic of constrictive pericarditis when the SAI is >1.1 [74].

CT imaging can show pericardial thickening and calcification but is not necessary to diagnose constrictive pericarditis. However, the identification of important vascular structures on CT can prove useful if planning for pericardiectomy [75]. Positron emission tomography (PET)/CT can also be helpful in predicting response to corticosteroid therapy [76]. CMRI may show characteristic changes of constrictive pericarditis, such as pericardial thickening, dilation of the inferior vena cava, or ventricular interdependence, but is usually necessary unless investigating other related cardiac pathology.
