A 29-year-old man was brought to the ER for a complaint of chest pain. He reported that the pain came on suddenly while he was playing soccer on a Saturday morning with some friends.
The pain quickly worsened to the point where he had to stop playing. When he laid down at home, the pain intensified. And by that evening, when I saw him, his pain was making it hard for him to take a breath.
As I entered the room, the patient was sitting on the stretcher leaning forward, clutching his chest. He said that it was the position that felt the best. He described the pain as sharp and non-radiating. He had never had anything like this in the past, and was otherwise healthy. He thought maybe he had strained his chest lifting weights in the gym the day before.
In the course of taking his history, I asked him if he had had any recent cough or fever, or other viral symptoms. He said he had a bad cold last week with a sore throat and runny nose, but got over it.
His vital signs were HR 105, RR 20, BP 118/75, and he was afebrile. His O2 saturation was 98% on room air.
His physical exam was unremarkable except for a pericardial friction rub, or a scratchy sound, which could be heard over the left sternal border while the patient was leaning forward.
An EKG showed ST elevation in all leads. His troponin blood test came back negative, but markers of inflammation were elevated. His chest X-ray was normal. U/S showed no pericardial effusion.
The patient was treated with ibuprofen for his pain, and also started on a three-month course of colchicine to help prevent recurrence. Arrangements were made for follow-up with cardiology. He was advised to avoid strenuous exertion until he was symptom-free, and cleared by cardiology.
Acute pericarditis can have many causes – cancer, autoimmune, trauma, post-MI, to name a few – but most often is due to a viral infection in immunocompetent patients. It can recur, and that is why patients are treated for 3 months with colchicine, or even longer in the case of a recurrent episode.
This patient’s presentation was classic: sudden onset sharp chest pain worsened by lying down, and improved with sitting up and leaning forward. The history of a recent viral infection was helpful in diagnosis, but in many cases the presentation is idiopathic with no preceding illness.
The physical finding of a pericardial friction rub is quite specific, but this finding can come and go, so it may be missed. Concave ST segment elevation is typical throughout most leads on the EKG. Often the troponin will not be elevated, but sometimes it is. Inflammatory markers such as ESR and C-reactive protein are often elevated.
In acute pericarditis, the chest x-ray is usually normal. A pericardial effusion may be present, but often is not, just like in this case.
Many patients with acute pericarditis will be discharged home from the ER for outpatient treatment with close follow-up. Certain features if present will require hospitalization. Some of these features include fever, a large pericardial effusion, or the presence of tamponade (JVD, perfusion impairment which occurs in about 1% of cases), immunocompromised, use of anticoagulant, acute trauma, elevated troponins (indicating myocarditis), or a patient that fails to improve after one week of outpatient treatment.
Patients with acute idiopathic pericarditis who follow recommended treatment have a good prognosis, and most often have no long-term consequences.
