From the Guidelines
Concurrent hypertrophic cardiomyopathy (HCM) and constrictive pericarditis can indeed mask diastolic dysfunction, creating significant diagnostic challenges. This occurs because HCM typically causes impaired relaxation and reduced compliance of the left ventricle, leading to elevated filling pressures and restricted filling, whereas constrictive pericarditis limits the overall cardiac filling but can paradoxically enhance early diastolic filling 1. When both conditions coexist, the constrictive component may partially normalize the abnormal filling patterns typically seen in HCM on echocardiography or other cardiac imaging, complicating diagnosis as standard parameters like E/A ratio, deceleration time, and tissue Doppler measurements may appear deceptively normal 1. Key considerations in diagnosing constrictive pericarditis include clinical presentation, ECG findings, chest X-ray, and the use of M mode/2D echocardiogram, Doppler, TEE, CT/MRI, and cardiac catheterization 1. Given the complexities, clinicians should maintain a high index of suspicion in patients with unexplained heart failure symptoms, particularly when there's a discrepancy between symptoms and conventional diastolic parameters 1. Comprehensive assessment using multiple imaging modalities including echocardiography with respiratory variation analysis, cardiac MRI, and possibly cardiac catheterization with simultaneous pressure measurements may be necessary to detect this dual pathology 1. It's also crucial to consider the pathophysiology of symptoms due to diastolic heart failure, which may be intertwined with other mechanisms such as myocardial ischemia, outflow obstruction associated with mitral regurgitation, and atrial fibrillation 1. Therefore, a thorough and multi-faceted approach is essential for accurate diagnosis and management of patients with concurrent HCM and constrictive pericarditis.
From the Research
Diastolic Dysfunction in Concurrent HCM and Constrictive Pericarditis
- Concurrent hypertrophic cardiomyopathy (HCM) and constrictive pericarditis can indeed mask diastolic dysfunction, making diagnosis challenging 2.
- A case report described a patient with HCM presenting with right-sided congestive heart failure symptoms, where noninvasive testing was suggestive but non-diagnostic for constrictive pericarditis 2.
- The presence of both HCM and constrictive pericarditis led to a lack of "modern" echocardiographic and invasive criteria for constrictive pericarditis, highlighting the need for careful consideration of classic hemodynamic criteria 2.
Diagnostic Challenges
- Differentiating between constrictive pericarditis and restrictive cardiomyopathy can be difficult, requiring meticulous attention to hemodynamic and Doppler echocardiographic features 3.
- Constrictive pericarditis can mimic heart failure with preserved ejection fraction (HFpEF), emphasizing the importance of timely recognition and further investigation with cardiac magnetic resonance (CMR) imaging and invasive biventricular pressure measurements 4.
Treatment and Outcomes
- Pericardiectomy can cure constrictive pericarditis, restoring satisfactory diastolic filling by removing the constrictive pericardium 5.
- In patients with HCM, calcium channel blockers can improve diastolic filling characteristics, leading to subjective and objective improvement, as well as a low death rate and little need for operation 6.
- Early diagnosis of constrictive pericarditis is crucial, as it can lead to significant clinical improvement and potentially prevent diastolic heart failure 5, 4.