Patient handout

Acute HF — constrictive pericarditis decompensation

PRODUCTION

1. Your condition

This handout is for acute hf — constrictive pericarditis decompensation. Your care team identified this based on: right-sided hf features (jvd, hepatomegaly, ascites, peripheral edema) dominant over pulmonary edema + preserved lv ef on echo → constrictive pericarditis pathway.

Other reasons your team may use this plan: 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; echo septal bounce + expiratory hepatic vein flow reversal + preserved lv ef + biatrial enlargement → cp suspicion + advanced imaging (cardiac mri + cath); pericardial calcification on ct chest or pericardial thickening >4 mm on cardiac mri in patient with hf symptoms — diagnostic of cp.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
furosemide	10-20 mg IV titrated to UOP + clinical response (NOT high-dose upfront — preload-dependent low-output state)	IV	q12-24h titrate	Gentle diuresis essential — over-diuresis precipitates pre-renal AKI in preload-dependent low-output state; titrate to symptom relief without hypotension; daily weight + BMP guides dosing
spironolactone	25-50 mg PO daily	PO	daily	Cardiac cirrhosis physiology — spironolactone first-line for ascites in cirrhosis (cardiac or hepatic); also K-sparing partner with loop diuretic
ibuprofen	600 mg PO TID × 2-4 wk then taper	PO	TID	ESC 2015 PMID 26320112 + Imazio CORP trials — NSAID first-line for active pericarditis; potentially reverses early constriction if active inflammation present (subset of "transient constrictive pericarditis" per Haley Mayo 2004)
colchicine	0.5 mg PO daily (<70 kg) or 0.5 mg PO BID (≥70 kg) × 3 mo	PO	daily-BID	ESC 2015 + Imazio CORP-2 PMID 24819631 — colchicine reduces recurrence + may prevent progression to chronic CP; renal dose-adjust
prednisone	0.25-0.5 mg/kg/d PO (LOW-DOSE per ESC 2015 — high-dose worsens pericarditis recurrence) × weeks then taper	PO	daily	ESC 2015 — low-dose only after NSAID + colchicine failure or in CTD; high-dose paradoxically increases recurrence (Imazio); IMPI PMID 25180860 — adjunct steroid in TB-CP failed primary endpoint but may reduce constriction in HIV-negative subset
isoniazid	5 mg/kg/d PO (max 300 mg) × 2 mo intensive then 4 mo continuation	PO	daily	WHO 2022 TB guideline — 4-drug intensive (HRZE) × 2 mo then HR × 4 mo; pyridoxine 25 mg daily for INH neuropathy prevention; pre-pericardiectomy ATT essential to avoid intra-op TB seeding
rifampin	10 mg/kg/d PO (max 600 mg)	PO	daily	WHO 2022 — part of HRZE intensive phase; many drug interactions (CYP3A4 inducer)
pyrazinamide	25 mg/kg/d PO (max 2 g) × 2 mo	PO	daily × 2 mo intensive only	WHO 2022 — intensive phase; hepatotoxicity + hyperuricemia common AEs
ethambutol	15-25 mg/kg/d PO × 2 mo	PO	daily × 2 mo intensive	WHO 2022 — intensive phase; optic neuritis monitoring; renal dose-adjust
metoprolol_succinate	12.5-25 mg PO daily titrate (LOW dose, careful — preload-dependent state)	PO	daily	AFib common in CP via atrial dilation; rate control essential but avoid HR <60 (impairs CO when stroke volume is fixed); BB preferred over CCB for HFrEF if coexisting LV dysfunction
apixaban	5 mg PO BID (or 2.5 mg BID per dose-reduction criteria)	PO	BID	ACC/AHA 2023 AFib (PMID 38033089) — DOAC preferred; apixaban for elderly per ARISTOTLE PMID 21870978

Plan: Constrictive pericarditis acute decompensation — gentle diuresis + treat active inflammation if applicable + pericardiectomy referral (ESC 2015 PMID 26320112; Khandaker Mayo Clin Proc 2010 PMID 20656240; IMPI PMID 25180860 for TB-CP)

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent decompensation → admission
Late residual constriction → repeat surgical evaluation
New LV dysfunction post-pericardiectomy → the four foundational heart-failure medications + cardiology
TB recurrence → ID + repeat workup

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Tense ascites unresponsive to diuretic + new renal dysfunction (rising creatinine, oliguria) — cardiac cirrhosis with hepatorenal-like physiology in CP
Radiation-associated CP requiring pericardiectomy — high surgical mortality (~30% per Murashita 2017) due to coexisting myocardial fibrosis, valvular disease, CAD, adhesions, and pulmonary fibrosis
Diagnostic uncertainty between RCM and CP after echo + MRI — both have preserved EF + diastolic dysfunction + biatrial enlargement; clinical implications major (CP curable, RCM not)
Post-pericardiectomy low-output syndrome (LOS) — LV dysfunction unmasked when constraint removed; CI <2.2 + lactate elevation + oliguria + hypotension despite adequate preload(life-threatening)
Pericardial effusion superimposed on constriction — tamponade physiology with elevated RA + JVD + Kussmaul + pulsus paradoxus; pericardiocentesis only partially relieves due to underlying constriction(life-threatening)

5. Follow-up

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 the four foundational heart-failure medications initiation)

6. Sources

Guideline: ESC 2015 pericardial diseases (Adler PMID 26320112) + Khandaker Mayo Clin Proc 2010 (PMID 20656240) + Sagristà-Sauleda EHJ 2002 (PMID 12122206) + IMPI for TB pericarditis (PMID 25180860)