Case Study: Young Man with Severe Chest Pain

By Marven Ewen, MD
Medical Director
He was sitting up leaning slightly forward when I entered the exam room. This 22-year-old man said he started having severe central chest pain that he described as sharp while playing soccer. He decided to lay down on the sidelines and see if it would go away, but it actually got worse when he laid down.

He tried some antacid that his coach gave him, thinking that it was probably just reflux because it worsened laying down. He thought that it helped, but then the pain came back when he started playing again. The pain had started about 2 hours before I saw him. It was no better in the ER.

I asked him to take a deep breath. He said the pain hurt more to do that. He denied radiation of the pain, cough or shortness of breath. On exam, his vital signs were normal. His chest was clear with normal respiratory effort. His heart sounds were normal with a regular rhythm but a pericardial rub was present. This is a scratchy (think sandpaper on wood) sound that is present in both systolic and diastolic phase. It is easily differentiated from a murmur by both timing and quality.

The remainder of his exam and review of systems were unremarkable. An ECG showed changes consistent with the diagnosis: acute pericarditis.

The symptoms of acute pericarditis are characterized by sudden onset of sharp central chest pain. Pain is usually worse lying down and feels best sitting up leaning forward slightly. It feels worse with deep breath. Sometimes there may be a low grade fever, malaise, or cough, but often not.

The pain is due to inflammation of the pericardial sac, the fibrous two walled sac that the surrounds the heart. Pericarditis is most often idiopathic (meaning we don’t know what causes it) or may be due to virus. Rarely there is some underlying rheumatologic disease. I have seen it more often in younger people. It should be considered as a possibility in all patients presenting with chest pain.

Often this condition will resolve on its own in a few days, but sometimes complications can develop due to accumulation of excessive fluid in the pericardium due to inflammation. In rare cases, this can lead to constrictive pericarditis impairing venous return to the heart. So generally when the condition is diagnosed the patient will be treated with anti-inflammatory medication to manage pain and prevent complications.

In this case, the patient seemed to get some transient improvement with antacids. You can’t rely on this when assessing chest pain. I have seen patients with pericarditis and even acute heart attacks that felt relief with antacids. This can be a placebo effect. Likewise, a tender chest wall doesn’t rule out a heart attack or other serious chest conditions. You can’t jump to conclusions – all the information needs to be evaluated.

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