Marked elevation of the jugular venous pressure should raise the index of suspicion for constrictive pericarditis.

Given the fact that, in the ‘constricting differential . . . ’, the successful management hinged crucially on the identification of the constrictive component of pericarditis, the latter component typically characterized by marked elevation of the jugular venous pressure (JVP), it would be useful to know how elevated that parameter was in the subject of the case report. In one series, 75% of 62 patients with constrictive pericarditis (CP) had an elevation in the JVP up to the angle of the jaw even when sitting up. In another series, comprising 25 patients with CP, 24 of whom had associated pleural effusion, the same degree of JVP elevation was noted in some of the subjects. Individual case reports also document this degree of elevation in JVP when CP is associated with pleural effusion. Second, given the fact that the JVP is elevated at a early stage of CP and is the last abnormal sign to disappear after successful pericardiectomy, was there a marked degree of elevation in JVP when the patient appeared to be responding to diuretics during the period antedating pericardiectomy? If that had been the case the index of suspicion for CP would have been even higher, given the fact that ‘a major clinical clue to the diagnosis (of CP) is the continued elevation of the central venous pressure after adequate diuresis’, the latter observation being borne out by 9 of the 11 cases reported by Conti and Friesinger. Conflict of interest: None declared.