HPI
• A 35 yo female presents to the ED with chest
pain that started this morning. She had coldlike symptoms earlier in the week. She has an
important presentation at work this afternoon
about her recent meeting with investors in
Japan and wants to know how long it is going
to take to find out what is wrong.
• What else would you like to ask?
HPI
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Onset
Setting
Severity
Quality
Location, Radiation
Duration
Frequency
Aggravating Factors
Alleviating Factors
Associated Symptoms
HPI
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Onset - Sudden, acute
Setting - Started when she woke up this morning
Severity - 10/10!
Quality - Sharp
Location, Radiation - Left-sided, radiating to left shoulder
Duration - 2 hours
Frequency - No previous episodes
Aggravating Factors - Inspiration, lying down, coughing,
swallowing
• Alleviating Factors - Sitting up and leaning forward
• Associated Symptoms - palpitations
• What else do you want to know?
PMH
• Medical Hx: C-section (2009)
• Family Hx: non-contributory, no family history of
heart disease or bleeding disorders
• Social: Married with 2 children, works in finance,
one glass of wine per week, denies tobacco and
illicit drug use
• What is your differential diagnosis?
DDx
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Acute MI
Pulmonary Embolism
Pneumothorax
Pneumonia
Pericarditis
Asthma
GERD
Anxiety
• What do you want to do next?
Physical Exam
• Vitals: BP 120/80, T 99.0, HR 80, RR 20
• General: Patient is sitting on the edge of the
hospital bed leaning forward
• HEENT, Abdominal, Neuro, and Psych Exams: wnl
• CV: RRR, no murmurs, rub heard at left lower
sternal border at the end of expiration
• Respiratory: shallow breaths, able to speak in full
sentences, lungs clear to auscultation bilaterally
• What labs do you want to order and why?
Lab Tests
• Cardiac Markers – rule out MI
• CBC – evaluate for infection, inflammation
• Electrolytes – increased risk of arrhythmias in
pericarditis
• CRP, ESR – evaluate for inflammation
• D-dimer – rule out PE (low suspicion)
• CXR – evaluate for pneumonia, pneumothorax,
PE, effusion
• ECG – rule out MI, pericarditis
Lab Results
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Troponin I - < 10 μg/L
CBC, electrolytes – normal
CRP – 16 mg/L
ESR – 25 mm/h
D-Dimer – 100 ng/mL
ECG
• What’s your impression of the ECG?
• Widespread ST elevation without reciprocal
depression
• PR depression in lead II
Chest X-Ray
• Note the
cardiomegaly
• How can we
further evaluate
this enlarged
heart?
Cardiac Echo
shows pericardial effusion
• RV – right
ventricle
• LV – left
ventricle
• LA – left atrium
• Ao – aorta
• PE – pericardial
effusion
Chest CT
– Thick arrow – pericardial effusion
– Thin arrow – pleural effusion
Overview of Acute Pericarditis
• Inflammation of the pericardial sac
accompanied by pericardial effusion
“Bread and Butter Heart”
Histology of Acute Pericarditis
– PMNs adhering to the epicardium
Overview of Acute Pericarditis
• Many possible causes, including:
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Idiopathic (usu. post-viral)
Infection (viral, bacterial, fungal)
Acute MI
Dressler’s syndrome
SLE
Drug-induced (procainamide, hydralazine)
Amyloidosis
Radiation
Post-surgery
Hallmarks of Acute Pericarditis
• Symptoms:
– Chest pain
• Pleuritic, associated with breathing
• Positional  relieved by sitting up and leaning forward
– Dyspnea
– Palpitations
– +/- fever, non-productive cough
Hallmarks of Acute Pericarditis
• ECG Changes – diffuse ST-segment elevation
and PR depression
• Physical Exam Findings:
– Friction rub
– Pulsus paradoxus
– Distant Heart Sounds
Pericardial Friction Rub
• Pathognomonic for acute pericarditis
• Heard best at left lower sternal edge with
patient sitting up, leaning forward, & exhaling
• High-pitched, grating sound with 3
components
• http://www.youtube.com/watch?v=J1R8Oxgq
hfk
Pulsus Paradoxus
• > 10 mmHg fall in systolic blood pressure
during inspiration
• Seen with cardiac tamponade, asthma,
pericarditis
Treatment
• NSAIDs, medium to high doses – 1st line
• Corticosteroids – if NSAIDs fail or are
contraindicated, recurrent pericarditis
• Colchicine – prevents recurrent pericarditis
• Pericardiocentesis – for large effusion with
hemodynamic compromise, cardiac
tamponade, or diagnostic purposes
• Pericardiectomy – for persistent constrictive
pericarditis
Pearls
• Acute Pericarditis Key Findings (need 2 of 4 for
diagnosis):
– Pleuritic chest pain improved by leaning forward
– Pericardial friction rub
– Widespread ST elevation on ECG
– Pericardial effusion
Summary
• The patient was diagnosed with acute
pericarditis and started on NSAID therapy
• She continued to be in stable condition and
was discharged from the ED with instructions
to follow-up with her PCP
• She was told to expect her symptoms to
resolve in 2 weeks to 3 months