Will C-reactive protein (CRP) be elevated in a patient with constrictive pericarditis, presenting with severe pitting edema of the lower extremities and shortness of breath, as indicated by a 2-dimensional echocardiogram (2D echo)?

CRP Elevation in Constrictive Pericarditis

CRP is typically NOT elevated in chronic constrictive pericarditis presenting with severe edema and dyspnea, as this represents an end-stage fibrotic process rather than active inflammation. However, CRP elevation may indicate a potentially reversible form of constriction where anti-inflammatory therapy could prevent progression to pericardiectomy.

Understanding the Clinical Context

Your patient presents with classic signs of chronic constrictive pericarditis—severe pitting edema, dyspnea, and echocardiographic confirmation. The key distinction is whether this represents chronic fibrotic constriction (CRP negative) versus transient inflammatory constriction (CRP positive) 1.

Chronic Constrictive Pericarditis (Most Likely Scenario)

• Chronic pericarditis with fibrosis and calcification leads to pericardial constriction and typically does NOT show CRP elevation 1.
• The clinical picture you describe—severe peripheral edema, dyspnea, and established constrictive physiology on echo—suggests a chronic process where the inflammatory phase has resolved 1.
• In chronic cases, the pericardium has undergone fibrosis and calcification, representing a mechanical rather than inflammatory problem 1.

When CRP May Be Elevated

CRP elevation in the setting of constrictive pericarditis identifies a subset of patients with potentially reversible disease 1:

• Transient constriction occurs in 10-20% of cases and may resolve with anti-inflammatory therapy within a few months 1.
• Detection of elevated CRP combined with imaging evidence of pericardial inflammation (contrast enhancement on CT/CMR) identifies patients where empiric anti-inflammatory therapy should be considered and may prevent pericardiectomy 1.
• In acute pericarditis, CRP is elevated in approximately 78% of cases at presentation, but this represents the acute inflammatory phase before constriction develops 2.

Diagnostic Algorithm

To determine if your patient has potentially reversible inflammatory constriction:

1. Measure CRP immediately 1:

   • If elevated: Consider CT or cardiac MRI to assess for pericardial enhancement indicating active inflammation 1
   • If normal: Suggests chronic fibrotic constriction requiring surgical pericardiectomy 1

2. If CRP is elevated with imaging evidence of inflammation:

   • Trial of anti-inflammatory therapy is reasonable before proceeding to surgery 1
   • This may prevent progression to permanent constriction requiring pericardiectomy 1

3. If CRP is normal (expected in your case):

   • Pericardiectomy is the mainstay of treatment for chronic permanent constriction 1
   • Medical therapy is only supportive for symptom control and should not delay surgery 1

Critical Clinical Pitfall

Do not delay pericardiectomy in advanced cases with severe symptoms waiting for CRP results or attempting prolonged anti-inflammatory therapy 1. Your patient with 4+ pitting edema and significant dyspnea likely has advanced disease where surgical intervention should not be postponed, as advanced cases have higher mortality and worse prognosis if surgery is delayed 1.

Prognostic Implications

• In acute pericarditis, persistent CRP elevation at week 1 is an independent risk factor for recurrence (HR 2.36,95% CI 1.32-4.21) 2.
• The inflammatory phenotype (CRP elevation plus pericardial effusion) in acute pericarditis is independently associated with increased risk of recurrences (OR 2.005,95% CI 1.454-2.765) 3.
• However, these data apply to acute pericarditis, not established chronic constriction 3, 2.

Bottom Line for Your Patient

Expect CRP to be normal or only minimally elevated in your patient with established chronic constrictive pericarditis and severe symptoms 1. The presence of 4+ pitting edema and dyspnea indicates advanced hemodynamic compromise requiring pericardiectomy as definitive treatment 1. Check CRP primarily to identify the rare patient with inflammatory constriction who might benefit from medical therapy, but do not let this delay surgical evaluation 1.