Observations of angina and myocardial infarction in constrictive pericarditis

The common symptoms of constrictive pericarditis, i.e. dyspnea on exertion, shortness of breath and cough, relate to impairment of ventricular filling and to a progressive rise in systemic and pulmonary venous pressures. Myocardial ischemia, angina and myocardial infarction are rarely associated with this disease. We have encountered two patients with constrictive pericarditis, one presenting with angina and the other with acute anterior wall infarction. Possible etiologies of constrictive pericarditis in the first case include cardiac surgery, chronic renal failure and myocarditis; in the second case, Crohn's disease. The proposed mechanism of chest pain in the first patient was a reduced cardiac output resulting in underperfusion of the coronary arteries, although it is possible that the patient experienced angina due to the presence of severe coronary artery disease. In the second patient an anterior wall infarction and post-infarction angina were attributed to obliteration of the left anterior descending artery by constraint of a thickened pericardium. In both cases non-invasive imaging modalities were not of use in establishing the diagnosis of constrictive pericarditis. Clinical awareness and accurate hemodynamic measurements continue to play a key role in the diagnostic process.