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cardio.acute-hf.constrictive-pericarditis-decompensation.v1

Acute HF — constrictive pericarditis decompensation

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.acute-hf.core.v1 — acute decompensation of constrictive pericarditis. Pathophysiology: rigid pericardium → impaired diastolic filling → R-sided > L-sided HF + low CO. Etiologies: post-cardiac-surgery (most common in developed countries), post-radiation (breast/lung/lymphoma — high surgical mortality ~30% per Murashita 2017), post-viral (idiopathic), TB (endemic regions; ~20-30% develop constriction; IMPI PMID 25180860), CTD, malignancy. Diagnosis: echo (septal bounce, expiratory hepatic vein flow reversal, annulus reversus, biatrial enlargement, preserved LV EF), cardiac MRI (pericardial thickening >4 mm + LGE for active inflammation), cath (rapid Y, dip-and-plateau, equalized RA/RV/PCWP, Hatle sign). Differential vs RCM essential. Treatment: GENTLE diuresis (10-20 mg furosemide IV — preload-dependent state); avoid pure vasodilators; rate control if AFib (avoid HR <60); active inflammation → NSAID + colchicine + steroid (low-dose) per ESC 2015; ATT for TB; PERICARDIECTOMY definitive for chronic CP at high-volume center. Post-pericardiectomy low-output state common (~15-30%) requiring inotropic support + GDMT initiation. Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (CP specifics documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (4)

  • symptom
    Right-sided HF features (JVD, hepatomegaly, ascites, peripheral edema) dominant over pulmonary edema + preserved LV EF on echo → constrictive pericarditis pathway
    right_sided_hf_dominant_with_preserved_lv_ef
  • history
    New right-sided HF in patient with prior CABG/valve/transplant OR mediastinal radiation (breast, lung, lymphoma — often years-decades delayed) — high pretest probability of CP
    prior_cardiac_surgery_or_mediastinal_radiation_with_new_hf
  • imaging
    Echo septal bounce + expiratory hepatic vein flow reversal + preserved LV EF + biatrial enlargement → CP suspicion + advanced imaging (cardiac MRI + cath)
    echo_septal_bounce_or_expiratory_hepatic_vein_flow_reversal
  • imaging
    Pericardial calcification on CT chest OR pericardial thickening >4 mm on cardiac MRI in patient with HF symptoms — diagnostic of CP
    pericardial_calcification_on_ct_or_thickening_on_mri

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Older patients more likely to have post-cardiac-surgery or post-radiation CP; younger patients more likely TB or post-viral; age also drives surgical risk for pericardiectomy
  • prior_cardiac_surgery_radiation_pericarditis_tb_ctd_historyrequired
    history • used at CONTEXT
    Etiology drives prognosis (radiation CP has worst surgical outcomes), reversibility (active inflammation may respond to anti-inflammatory therapy avoiding surgery), and adjunct therapy (ATT for TB, steroids for CTD)
  • echo_with_diastolic_function_septal_motion_tdirequired
    imaging • used at INITIAL_WORKUP
    Septal bounce, expiratory hepatic vein reversal, respirophasic interventricular septal shift, annulus reversus (medial e prime > lateral e prime — preserved or elevated), preserved LV systolic function, biatrial enlargement — distinguishes from restrictive cardiomyopathy
  • cardiac_mri_for_pericardial_thickness_lge_tagged_imaging
    imaging • used at BRANCHING_WORKUP
    Pericardial thickening >4 mm + late gadolinium enhancement (active inflammation = potentially reversible) + tagged imaging showing pericardial-myocardial adhesion — gold standard noninvasive
  • ct_chest_for_pericardial_calcification
    imaging • used at BRANCHING_WORKUP
    Pericardial calcification (~25% of CP cases — pathognomonic when present) + thickening; alternative to MRI when MRI contraindicated; also evaluates lung pathology for radiation/TB
  • right_and_left_heart_cath_with_simultaneous_pressures
    imaging • used at BRANCHING_WORKUP
    Definitive hemodynamic confirmation: rapid Y descent in RA, dip-and-plateau (square root) sign in RV/LV diastolic pressures, equalization of RA/RV/PCWP within 5 mmHg, ventricular interdependence with discordant systolic pressures (Hatle sign) — high specificity for CP vs RCM
  • sbp_dbp_hr_jvp_for_hemodynamicsrequired
    vital • used at INITIAL_WORKUP
    JVP elevation + Kussmaul sign + pulsus paradoxus (less prominent than tamponade) + low SBP often + narrow pulse pressure — clinical exam essential
  • bnp_or_nt_probnprequired
    lab • used at INITIAL_WORKUP
    BNP often disproportionately LOW in CP relative to symptoms (myocardium not stretched due to constraint) — markedly elevated BNP favors RCM; useful differential clue
  • creatinine_egfr_with_lftsrequired
    lab • used at CONTEXT
    eGFR drives diuretic dosing; chronic R-sided HF causes hepatic congestion + cardiac cirrhosis (elevated bilirubin, AST/ALT, INR — pseudo-hepatorenal physiology)
  • inflammatory_markers_esr_crp_for_active_inflammationrequired
    lab • used at BRANCHING_WORKUP
    Elevated ESR/CRP + LGE on MRI suggests active inflammation potentially responsive to anti-inflammatory therapy (NSAID + colchicine ± steroid) per ESC 2015 — may avoid surgery in subset
  • tb_workup_if_endemic_or_risk_factors
    lab • used at BRANCHING_WORKUP
    TB pericarditis common in endemic regions + immunosuppressed; PPD/IGRA, AFB cultures, pericardial fluid (if drainable) for TB PCR + ADA; ATT essential before pericardiectomy (avoid intra-op TB seeding)

12-phase flow (10)

  1. 1FRAME
    Constrictive pericarditis decompensation: rigid pericardium → impaired diastolic filling → R-sided > L-sided HF + low CO; etiology drives surgical risk (radiation worst); definitive therapy is pericardiectomy; gentle diuresis acutely; differentiate from RCM
    inputs: echo_with_diastolic_function_septal_motion_tdi
    advance: CP framed
  2. 2ENTRY
    Recognize R-sided HF dominance + preserved LV EF + relevant history (prior surgery, radiation, pericarditis, TB); start gentle diuresis; avoid aggressive diuresis or pure vasodilators; ICU if hemodynamically unstable
    inputs: sbp_dbp_hr_jvp_for_hemodynamics
    advance: gentle diuresis initiated
  3. 3CONTEXT
    Etiology screen (cardiac surgery, mediastinal radiation, prior pericarditis, TB exposure, CTD, malignancy, uremia); functional status; comorbidities (CAD if radiation — coexisting); surgical candidacy assessment
    inputs: age, prior_cardiac_surgery_radiation_pericarditis_tb_ctd_history, creatinine_egfr_with_lfts
    advance: context complete
  4. 4RED_FLAGS
    Hemodynamic instability with hypotension despite gentle diuresis; refractory ascites with renal dysfunction (cardiac cirrhosis physiology); active TB pericarditis (life-threatening + contagious); progressive cachexia (cardiac cachexia from chronic R-sided HF); cardiac tamponade physiology if effusive-constrictive (transient — fluid + constrictive component)
    inputs: sbp_dbp_hr_jvp_for_hemodynamics
    actions: acute_pulm_edema, cardiac_tamponade
    advance: red flags screened
  5. 5INITIAL_WORKUP
    CBC + BMP + LFTs (R-sided HF → cardiac cirrhosis) + INR + coags + BNP/NT-proBNP + ESR/CRP + TSH + ECG + CXR (pericardial calcification visible on lateral) + bedside echo (septal bounce, hepatic vein flow, annulus reversus, biatrial enlargement)
    inputs: echo_with_diastolic_function_septal_motion_tdi, bnp_or_nt_probnp, inflammatory_markers_esr_crp_for_active_inflammation
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    Cardiac MRI (pericardial thickness + LGE for active inflammation + tagged imaging) + CT chest (calcification + lung pathology) + right and left heart cath (rapid Y, dip-and-plateau, equalization, Hatle sign) for hemodynamic confirmation + differential vs RCM; TB workup (PPD/IGRA, AFB, pericardial fluid TB PCR + ADA if endemic or at-risk); CTD serologies if suggestive; if effusive-constrictive — TTE-guided pericardiocentesis with re-measurement of RA pressure post-drainage (persistent elevation → constriction component)
    inputs: cardiac_mri_for_pericardial_thickness_lge_tagged_imaging, ct_chest_for_pericardial_calcification, right_and_left_heart_cath_with_simultaneous_pressures, tb_workup_if_endemic_or_risk_factors
    actions: cardiac_tamponade
    advance: etiology confirmed + RCM excluded
  7. 7TREATMENT
    Acute medical: gentle loop diuresis (furosemide 10-20 mg IV titrated, avoid over-diuresis); rate control if AFib (BB or non-DHP CCB cautiously — preserve preload); avoid pure vasodilators; if active inflammation (high CRP + LGE) — NSAID (ibuprofen 600 mg PO TID + colchicine 0.5 mg PO daily-BID per ESC 2015 + Imazio CORP trials); steroids if CTD or refractory; ATT for TB pericarditis (4-drug × 2 mo + 2-drug × 4 mo per WHO + IMPI PMID 25180860 + steroids per IMPI failed primary endpoint but may help in HIV-negative subset); definitive: pericardiectomy referral for chronic CP without active inflammation (best outcomes for idiopathic; high mortality for radiation per Murashita 2017); inoperable: chronic gentle diuresis + supportive care + palliative care discussion
    inputs: inflammatory_markers_esr_crp_for_active_inflammation
    advance: medical optimization + surgical pathway determined
  8. 8DISPOSITION
    ICU if hemodynamically unstable or refractory ascites; telemetry floor for moderate decompensation; outpatient if stable + medical optimization adequate; surgical referral for pericardiectomy planning at high-volume center
    advance: unit assigned + surgical pathway documented
  9. 9MONITORING
    Continuous SpO2 + ECG + BP (hypotension risk with diuresis in preload-dependent state); strict I/O; daily weight + abdominal girth (ascites); daily BMP for AKI + electrolytes; serial JVP exam; INR + LFTs for cardiac cirrhosis trend; echo at 4-6 wk post-anti-inflammatory therapy if active inflammation (assess reversibility before surgery)
    inputs: creatinine_egfr_with_lfts
    actions: panel.cardiac, panel.renal
    advance: monitoring active
  10. 10FOLLOWUP
    Cardiac surgery referral for pericardiectomy at high-volume center if surgical candidate; cardiology follow-up at 1-2 weeks; nephrology if cardiorenal physiology; hepatology if cardiac cirrhosis; ID + pulmonary if TB; oncology if radiation; post-pericardiectomy follow-up at 1 wk + 1 mo + 3 mo + 6 mo (low-output state in early post-op period requires close monitoring; LV dysfunction may unmask requiring GDMT initiation)
    advance: long-term plan documented + surgical referral booked