CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 5, June 2012
AFRICA
281
Review Article
The prevalence and outcome of effusive constrictive
pericarditis: a systematic review of the literature
MPIKO NTSEKHE, CHARLES SHEY WIYSONGE, PATRICK J COMMERFORD, BONGANI M MAYOSI
Abstract
There is sparse information on the epidemiology of effusive
constrictive pericarditis (ECP). The objective of this article
was to review and summarise the literature on the preva-
lence and outcome of ECP, and identify gaps for further
research. The prevalence of ECP ranged from 2.4 to 14.8%,
with a weighted average of 4.5% [95% confidence interval
(CI) 2.2–7.5%]. Sixty-five per cent (95% CI: 43–82%) of
patients required pericardiectomy regardless of the aetiol-
ogy. The combined death rate across the studies was 22%
(95% CI: 4–50%). The prevalence of ECP is low in non-
tuberculous pericarditis, while pericardiectomy rates are
high and mortality is variable. In this review, of 10 patients
identified with tuberculous ECP, only one presumed case
had a definite diagnosis of ECP. Appropriate studies are
needed to determine the epidemiology of ECP in tuberculous
pericarditis, which is one of the leading causes of pericardial
disease in the world.
Keywords:
effusive constrictive pericarditis, prevalence, peri-
cardiectomy and death
Submitted 14/6/11, accepted 22/11/11
Cardiovasc J Afr
2012;
23
: 281–285
DOI: 10.5830/CVJA-2011-072
Effusive constrictive pericarditis (ECP) is a clinical
haemodynamic syndrome in which constriction of the heart by
the visceral pericardium occurs in the presence of a compressive
pericardial effusion. ECP is believed to be a rare manifestation
of pericardial disease
1
that occurs as part of a continuum from
effusive to constrictive pericarditis. The outcome of ECP
with regard to the development of constrictive pericarditis,
pericardiectomy rates and death is not well defined.
2
In the
only prospective study of ECP, the prevalence was 6.8% of
patients undergoing pericardiocentesis and 1.2% of all patients
referred with effusive pericarditis.
3
In the same study, 46.7%
of participants with the diagnosis underwent pericardiectomy
within four months, and the overall mortality rate was 60% over
the subsequent seven-year mean follow-up period.
3
The influence of the aetiology of pericarditis on the prevalence
and outcome of ECP is not known. For example, tuberculous
pericarditis is associated with significant inflammation,
4
chronicity,
5
and a high rate of development of constrictive
pericarditis in about 25% of cases.
5-7
It is likely therefore that the
prevalence of ECP in patients with tuberculous pericarditis may
be much higher than seen in acute forms of pericardial disease,
such as idiopathic or viral pericarditis, which have formed the
basis of the previous studies of ECP.
8
With regard to the natural history, in the study of Sagrista-
Sauleda, those with neoplastic disease had a high mortality and
low pericardiectomy rate, whereas those with idiopathic disease
had a low mortality rate but high pericardiectomy rate.
3
The
impact of the aetiology of pericarditis on these outcomes of ECP
among patients whose life expectancy is not severely limited by
malignant disease is not known.
There are very few investigators who have used the ‘gold
standard’ to establish the diagnosis of ECP, which is invasive
measurement of intra-pericardial and intra-cardiac pressures
before and after pericardiocentesis.
2
Even though non-invasive
tools, such as echocardiography and magnetic resonance imaging
are gaining wider acceptance as methods for establishing the
diagnosis,
9
none has been compared to invasive haemodynamic
diagnosis of ECP.
9,10
It has been proposed that visceral pericardiectomy may
be necessary for a good clinical result in cases with ECP
because drainage of pericardial fluid alone leads to incomplete
relief of cardiac compression.
3
The timely recognition of ECP
therefore enables the clinician to choose the most appropriate
therapy. Information about the prevalence and outcome of
ECP is particularly important in the developing world, where
tuberculosis causes hundreds of thousands of cases of pericarditis
every year.
5
There are at present no recommendations on the
diagnosis and management of ECP in tuberculous pericarditis.
We have conducted a systematic review of the literature to
determine the prevalence and outcome of ECP in patients with
viral, tuberculous, uraemic, purulent and idiopathic pericarditis.
The outcomes of interest were pericardiectomy and mortality
rates at 12 months. Furthermore, we determined whether the
prevalence and the outcome of ECP were related to the aetiology
of the effusion. We limited the review to observational studies of
pericarditis due to these non-neoplastic medical conditions that
commonly progress to constrictive pericarditis.
1
Cardiac Clinic, Department of Medicine, Groote Schuur
Hospital and University of Cape Town, Cape Town, South
Africa
MPIKO NTSEKHE, MD, PhD,
PATRICK J COMMERFORD, MBChB
BONGANI M MAYOSI, DPhil (Oxon)
Institute of Infectious Disease and Molecular Medicine, and
School of Child and Adolescent Health, University of Cape
Town, Cape Town, South Africa
CHARLES SHEY WIYSONGE, MD
