CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 5, June 2012
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AFRICA
because of progression to non-effusive fibrous constrictive
pericarditis.
Discussion
This systematic review highlights that there are very few
prospective studies on the prevalence and outcome of ECP. The
prevalence of this syndrome in the available studies ranged from
1.4 to 14%. Although there was little information to ascertain
the mortality rate reliably, the pericardiectomy rate was clearly
high (44–100%).
There was a total of 10 participants who had effusive
constrictive tuberculous pericarditis in this review, one of whom
had a definite diagnosis of ECP. Commerford and Strang have
suggested that ECP may be a common form of presentation of
tuberculous pericarditis that frequently progresses to fibrous
constrictive pericarditis.
8
By contrast, the IMPI Africa Registry
has suggested that using clinical criteria alone, ECP may be
present in only 15% of cases of tuberculous pericarditis.
23
The results of this comprehensive review show a low
prevalence of ECP in patients with tuberculous pericarditis,
which ranged from 3 to 14%. It is noteworthy that there are no
studies that have systematically used an invasive haemodynamic
method to establish the diagnosis of effusive constrictive disease
in patients with tuberculous pericarditis. There is therefore a
need for a definitive study of the prevalence of tuberculous ECP
that is based on invasive haemodynamic methods.
Although the pericardiectomy rate across the studies was
high, the indications for surgical intervention were not uniform
among the 13 participants who had the operation. A significant
proportion of patients who were managed conservatively had
complete resolution of their effusive constrictive disease. This
suggests that there is room for a study to test a strategy of
watchful waiting compared to prophylactic pericardiectomy in
those without persistence of heart failure.
Finally, the mortality rate for tuberculous pericarditis in the
HIV era is as high as 40% in patients with AIDS, at the end of six
months of treatment with anti-tuberculosis medication.
24
Despite
the absence of data on mortality in patients with non-neoplastic
ECP, it is possible that because of its well-documented
haemodynamic sequelae,
2
the pericardial syndrome is associated
with a higher mortality rate than those without the syndrome.
Conclusion
In light of the lack of clarity on the prevalence of ECP
among patients with proven tuberculous pericarditis, the role
of prophylactic pericardiectomy in cases of varying aetiology,
and the impact of the syndrome on mortality, a study of well-
characterised participants with adequate follow up and clearly
defined outcomes is required to inform the development of
clinical guidelines on the diagnosis and management of effusive
constrictive pericardial disease.
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TABLE 2. 12-MONTH MORTALITYAND PERICARDIECTOMY RATES OF PARTICIPANTSWITH NON-NEOPLASTIC
EFFUSIVE CONSTRICTIVE PERICARDITIS
Study
Absolute number of study
participants with
non-neoplastic ECP
Number of patients with ECP who
underwent pericardiectomy within
12 months
Number of patients with ECP dead at 12 months
Sagrista-Sauleda 2004
11
7/11 (64%)
Mortality data at 12 months not available for all patients
Reuter 2007
5
2/5 (40%)
2/5 (40%)
Tsang 2003
4
4/4 (100%)
0/4 (0%)
Nugue 1996
2
Pericardiectomy data not available
Mortality data not available
George 2004
4
Pericardiectomy data not available
Mortality data not available
Total
26
13/20 (65%)
2/9 (22%)
