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Abstract & Commentary
Synopsis: A small subset of patients with evidence of pericardial constriction, perhaps 1 in 6, experience spontaneous resolution without surgical intervention.
Source: Haley JH, et al. J Am Coll Cardiol. 2004;43: 271-275.
Traditionally, constrictive pericarditis has been characterized as a rare progressive fibrosis, with or without calcification, of the pericardium, which leads to refractory heart failure unless surgical resection of the pericardium is performed. Recently, there have been reports of spontaneous remissions, such as the one by Sagrista-Sauleda et al (see page 19). Thus, Haley and colleagues at the Mayo Clinic in Rochester, Minn, report their experience with 36 such patients seen over a decade. The cases were obtained by identifying 212 patients in their echocardiography database who had signs of pericardial constriction. Of these, 36 showed spontaneous resolution of the echocardiographic findings and represent the subjects of this report. Almost all of these patients had symptoms (92%), with chest pain (53%) and dyspnea (44%) being the most common. Among the 22 patients who were seen for their entire illness at Mayo, resolution occurred in a mean of 8 weeks. Most (86%) received medical treatment; nonsteroidal anti-inflammatory agents (56%) and corticosteroids (44%) were the most common. After a mean follow-up of 2.3 years, there have been no recurrences. A pericardial effusion was documented in 24 patients (67%), 8 of whom underwent pericardiocentesis. Among the 17 who had CT or MRI, 10 (59%) showed increased pericardial thickening. A variety of presumed causes were determined, which were generally consistent with the usual causes of pericarditis. Haley et al concluded that a small subset of patients with evidence of pericardial constriction, perhaps 1 in 6, experience spontaneous resolution without surgical intervention.
Comment by Michael H. Crawford, MD
Although it is a retrospective, observational study from a referral center, several important points emerge from this report. The data suggest that in the course of acute pericarditis some patients develop constrictive physiology presumably due to a transiently thickened and inelastic pericardium, which resolves as the disease process abates. A smaller, earlier report from Sagrista-Sauleda et al1 suggested that transient constriction may occur in up to 10% of acute pericarditis cases. The evidence cannot be estimated from the Mayo report because it is a retrospective analysis of patients with constriction on echo. Why some patients go on to chronic constriction is not clear, but it is interesting that one diagnostic cause of pericarditis is missing in this report, namely radiation. Perhaps radiation-induced constrictive pericarditis is less likely to resolve spontaneously.
The practical implication of this report is that findings of constrictive pericarditis on echocardiography in patients with acute pericarditis should be treated expectantly with specific and nonspecific therapy, with an expected resolution in about 3 months if there is going to be resolution. Patients with persistent symptomatic constriction after 3-6 months should be considered for surgery. This advice probably does not apply to patents with chronic constrictive pericarditis who present long after their initial illness for evaluation or in whom the initial bout of pericarditis was never recognized. Spontaneous resolution would be much less likely in such individuals.
Dr. Crawford, Professor of Medicine, Associate Chief of Cardiology for Clinical Programs University of California San Francisco, is Editor of Clinical Cardiology Alert.
1. Sagrista-Sauleda J, et al. Am J Cardiol. 1987;59: 961-966.