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Spontaneous Circulation: A Constricting Diagnosis

Bruen, Charles MD

doi: 10.1097/01.EEM.0000440692.44141.40
Spontaneous Circulation

Dr. Bruenis a fellow in critical care medicine and emergency cardiology at Hennepin County Medical Center in Minneapolis. He has special interest in stabilization, resuscitation, hemodynamic evaluation, and emergency cardiovascular care.





A 58-year-old man presented to the ED with two days of exertional shortness of breath and constant 8/10 “tightness” chest pain radiating to both sides of his neck. He had noted that he fatigued easily and had been sleeping more over the previous several months. He was not taking any medication and did not smoke.

His vital signs revealed mild tachycardia and tachypnea, but otherwise were normal. His lungs were clear, but an abnormal heart sound was present in diastole though no murmur was noted. He had moderate pedal edema, and the remainder of his physical exam was unremarkable. CT cross-sectional imaging of his chest was obtained. (See photo.)

The patient was diagnosed with constrictive pericarditis. Physical examination can reveal general signs of reduced cardiac output and systemic congestion such as malaise, fatigue, decreased exercise tolerance, peripheral edema, systemic venous congestion, ascites, hepatic congestion, portal hypertension, and pleural effusions. These symptoms develop from the significant effects that constriction has on cardiac hemodynamics. The principal physiologic abnormality is impaired cardiac filling.

The noncompliant pericardium decreases diastolic filling, increases intracardiac pressures, and isolates intracardiac pressures from intrathoracic pressures. The enclosed pericardial space prevents the normal distensibility of the myocardium by the transmural pressures, so end-diastolic pressures are equal in all four cardiac chambers. The reduced compliance of the pericardium also limits the end-diastolic volume of both ventricles, which leads to elevation of the filling pressures. The myocardium itself is normal, and therefore systole is unimpaired. The presence of a noncompliant pericardium limits the transmission of intrathoracic pressure to the heart so there is reduced respiratory variation.

Find a complete case discussion and more information on constrictive pericarditis by reading Spontaneous Circulation in EMN's iPad App on Dec. 5 or in the Spontaneous Circulation blog at on Dec. 12, where additional EKGs are also available.

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