6 The 2025 ESC Guidelines recommend testing for elevated markers of inflammation, such as CRP, ESR and neutrophilic leukocytosis, to provide additional diagnostic supportive criteria. CT is recommended to evaluate pericardial thickness, calcifications, masses and loculated pericardial effusions as well as concomitant pleuropulmonary diseases and chest abnormalities. CMR is recommended in patients with suspected pericarditis when a diagnosis cannot be made using clinical criteria to assess evidence of pericardial thickening, edema or LGE and to assess the persistence of disease during follow-up in selected cases.14 Incessant pericarditis is defined as patients with persistent symptoms lasting longer than four to six weeks (but less than three months) who have no clear period of remission after the acute episode. The probability of developing incessant pericarditis as reported by Cremar et al. (2016) is approximately 15%-20%.12 Chronic pericarditis refers to patients who have symptoms lasting longer than three months.12 Constrictive pericarditis is an uncommon complication of viral pericarditis, occurring in less than 1% of cases, but can occur in any form of pericarditis, except rarely with recurrent pericarditis.1,8,13 Development of fibrous thickening or calcification of the pericardium results in pericardial noncompliance presenting as a clinical form of heart failure.7,12,13,15 The hemodynamic alterations occurring in constrictive pericarditis are the dissociation of intrathoracicintracardiac pressures and enhanced ventricular interaction.13,15 On inspiration, the noncompliant pericardial sac impedes the transmission of pressure in the pulmonary veins to the left ventricle (LV), causing an inspiratory reduction in venous return to the LV and permitting the ventricular septum to move toward the LV. During inspiration, the right ventricle (RV) stroke volume increases, and the LV stroke volume decreases, resulting in the pulsus paradoxus, a decrease in blood pressure greater than 10 mm Hg with inspiration.7,13,15 Symptom presentation includes fatigue, peripheral edema, dyspnea and abdominal distention. Physical examination findings may include jugular venous distention, increased central venous pressure and hepatomegaly. The central venous pressure may be so high that the examiner has the patient stand up to appreciate venous pulsations.12,16 Diagnostic testing includes chest X-ray, echocardiography, CT, CMR and cardiac catheterization in determining a differential diagnosis. Laboratory findings include slight elevations in creatinine and liver enzymes (alkaline phosphatase).7,12,13,15 There are three subtypes of constrictive pericarditis as described by Adler et al. (2015):1 Transient constrictive pericarditis This is a temporary form of constriction due to the inflammation occurring with pericarditis, usually involving a mild effusion. It resolves once the inflammation subsides after a course of antiinflammatory therapy. Effusive constrictive pericarditis Although pericardial fluid is typically not present in patients with constrictive pericarditis, for some a pericardial effusion further restricts cardiac filling and can cause cardiac tamponade. It is an uncommon occurrence in developed countries, usually with idiopathic pericarditis, but can be associated with radiation, neoplasm, chemotherapy, infection (especially TB and purulent forms) and post-surgical pericardial disease. Pericardiocentesis and monitoring of intracardiac pressures, such as right heart pressure and systemic arterial blood pressure, are recommended. CMR can be useful in evaluating pericardial thickness, cardiac morphology and function. Chronic constrictive pericarditis Characterized as a persistent constriction lasting longer than three to six months, it may exhibit heart failure NYHA class III or IV symptoms.
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