HISTORY

38-year-old man.

CHIEF COMPLAINT: Severe chest pain of several hours duration.

PRESENT ILLNESS: The patient was awakened from sleep by substernal

chest pain. The pain is “sharp,” is enhanced by breathing and improved by

sitting up. He recently recovered from an upper respiratory infection. There is

no history of trauma, chest surgery, tuberculosis, drug abuse or blood

transfusions. He has a history of hypertension treated with a beta-adrenergic

blocking drug. There are no other risk factors for coronary disease.

Question: What diagnostic possibilities are suggested by this history?

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Answer: The most likely diagnoses include pericarditis, pneumonia and

pulmonary embolism. Acute myocardial infarction and aortic dissection

are other possibilities. Additional causes of acute chest pain

include musculoskeletal disorders, spontaneous pneumothorax and

gastrointestinal disorders.

Acute pericarditis is the most likely cardiac diagnosis because of the “pleuritic”

and positional characteristics of the chest pain in a patient with a recent viral

upper respiratory infection. Acute myocardial infarction remains a diagnostic

consideration, especially since infarction can be complicated by pericarditis. In

any patient with chest pain and a history of hypertension, aortic dissection

should be considered.

Proceed

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PHYSICAL SIGNS

a. GENERAL APPEARANCE - Diaphoretic, anxious man leaning forward

(temperature = 100.4º).

b. VENOUS PULSE - The CVP is estimated to be 5 cm of H2O.

Question: What is your interpretation of the venous pulse?

URSE

PHONO

JVP

S2 S1 S2 S1 S2 S1

a a h

v

y

c

x

Answer: The venous pulse is normal in mean pressure and wave form.

Although this wave form is different from that seen in some normal patients, it is

commonly seen, especially in young healthy individuals with slow heart rates.

A small “a” wave due to right atrial contraction precedes a prominent systolic “x”

descent due to atrial relaxation that is interrupted by the “c” wave transmitted

from the carotid. Next, the small “v” wave reflects passive filling of the right

atrium, and the “y” descent reflects emptying of the right atrium after the

tricuspid valve opens. The “h” wave follows, due to continued gradual filling of

the right heart in mid to late diastole. The “h” and “a” waves are subtle, and the

following “x” descent stands out as the dominant event in this variant of

normal.

Proceed

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c. ARTERIAL PULSE - (BP = 130/85 mm Hg)

Question: How do you interpret the blood pressure and arterial pulse?

UPPER RIGHT

STERNAL

EDGE

CAROTID

ECG

S1 S2

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Answer: The blood pressure and arterial pulse contour are normal.

d. PRECORDIAL MOVEMENT

Question: How do you interpret the apical impulse?

PHONO

UPPER RIGHT

STERNAL

EDGE

S1 S2 PHONO

UPPER RIGHT

STERNAL

EDGE

APEXCARDIOGRAM

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Answer: The apical impulse is normal.

e. CARDIAC AUSCULTATION

Question: How do you interpret these acoustic events?

EXPIRATION INSPIRATION

ECG

ULSE

LLSE

APEX

S1 S2

S1 S2

S1 S2

S1

S1 S2

S1 S2

0.4 sec

A2 P2

Answer: The first and second heart sounds are normal with physiologic

splitting of S2. There are high frequency, scratchy, “to and fro,” systolic and

diastolic rubs along the left sternal border. Only the systolic component is

heard at the apex. The rubs are louder with expiration.

The typical triphasic pericardial friction rub has three components that

correspond to 1) atrial contraction, 2) ventricular contraction and 3) ventricular

relaxation.

Pericardial rubs may be subtle, evanescent and vary with time and respiration.

The rub may only have one or two components. If heard only in systole, it may

simulate a murmur. Repeated careful auscultation with the patient in different

positions and with exaggerated respiration may be required to detect a soft rub.

They may increase, decrease or remain unchanged with breathing.

f. PULMONARY AUSCULTATION

Question: How do you interpret the acoustic events in the pulmonary lung

fields?

Proceed 30-8

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Answer: In the left lower lung fields, there is a pleural rub (timed with

inspiration), reflecting pleural involvement in the pericardial inflammatory

process. In all other lung fields, there are normal vesicular breath sounds.

ELECTROCARDIOGRAM

Question: How do you interpret this electrocardiogram?

V1 V2 V3 V4 V5 V6

aVF aVL aVR III II I

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Answer: The ECG shows diffuse ST elevation with upward concavity, ST

depression in aVR, and PR depression (I, II) without pathologic Q waves of

infarction. These are typical findings of acute pericarditis.

CHEST X RAYS

Questions:

1. How do you interpret the chest X rays?

2. Based on the history, physical examination, ECG and chest X rays, what is

your diagnostic impression?

PA LATERAL

Answers:

1. The chest X rays show a mildly enlarged cardiac silhouette with clear

lung fields.

2. The history, physical examination, ECG and chest X rays are consistent

with acute pericarditis.

When acute pericarditis appears in an otherwise healthy individual,

especially with a respiratory or gastrointestinal illness within the preceding

weeks, a viral (Coxsackie A or B, influenza A or echovirus) etiology is most

likely. Other etiologies were ruled out by appropriate laboratory studies

(e.g., AIDS, tuberculosis, uremia, etc.).

Question: Would an echocardiogram be helpful?

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LABORATORY (continued) Answer: Yes. Echocardiography will identify the presence and

hemodynamic significance of pericardial fluid and determine ventricular

function. The patient’s study is shown below.

Question: How would you interpret this echocardiogram?

TWO DIMENSIONAL ECHOCARDIOGRAM

PARASTERNAL LONG AXIS

RV = Right Ventricle

LV = Left Ventricle

Ao = Aorta

LA = Left Atrium

Answer: This still frame illustrates the posterior echo free space of a

pericardial effusion (PE). The real time study also revealed normal cardiac size

and function.

Question: Should pericardiocentesis be performed?

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Answer: Pericardiocentesis is not indicated in this case. In selected

patients, pericardiocentesis will clarify the diagnosis and is indicated to relieve

cardiac tamponade.

Echocardiography will determine the location and amount of fluid, as well as its

hemodynamic significance, i.e., if cardiac tamponade is present. It may also be

used as an accurate guide for pericardiocentesis, a dramatically effective

treatment.

This patient was treated with a non-steroidal anti-inflammatory drug (NSAID),

but his pain increased significantly over the next 48 hours.

Question: What therapy would you now consider?

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Answer: Although an NSAID is usually the drug of choice, in more

refractory cases, corticosteroids may be dramatically effective. Occasionally,

prolonged and/or recurrent drug treatment may be indicated.

This patient responded to an NSAID with increasing dosage, and after 24 hours

his chest pain improved.

Question: Besides recurrence, what are the major complications

of pericarditis?

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Answer: Two major complications of pericarditis are cardiac tamponade

and constrictive pericarditis.

Tamponade results from the rapid accumulation of pericardial fluid causing

compression of the heart and limitation of ventricular filling. The clinical

presentation may be dramatic. The classical history is that of progressive

shortness of breath. Hallmarks on physical exam include sinus tachycardia,

elevated central venous pressure, and a paradoxical arterial pulse.

Question: What is a paradoxical arterial pulse?

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Answer: Systolic blood pressure falls during inspiration due to a drop in

intrathoracic pressure, pooling of blood in the pulmonary vessels and a

decrease in left ventricular filling. Normally, the magnitude of this change is

less than 10 mm Hg, while in tamponade the drop is greater. This is called a

paradoxical pulse, a misnomer since it is an exaggeration of the normal

inspiratory drop in systolic blood pressure.

In tamponade there is a high intrapericardial pressure limiting total cardiac

filling. Since inspiration increases right heart filling, the result is an obligatory

greater than normal inspiratory decrease in left heart filling, stroke volume and

systolic blood pressure.

A paradoxical pulse is not pathognomonic of tamponade; e.g., it may be seen

in obstructive pulmonary disease, constrictive pericarditis, restrictive

cardiomyopathy and hypovolemic shock.

Proceed

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The other major complication of pericardial disease is constrictive pericarditis.

In constrictive pericarditis, a fibrotic, thickened and adherent pericardium

prevents diastolic filling of both ventricles. It is usually a late complication of

pericarditis. Gradually progressive dyspnea, peripheral edema and ascites are

common. Additional findings may include atrial fibrillation, a narrow pulse

pressure, an elevated central venous pressure with rapid and deep “x” and “y”

descents, the absence of precordial impulses and a pericardial “knock”

on auscultation.

Proceed

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SUMMARY

The pericardium consists of an outer (parietal) layer and an inner (visceral)

layer. There is normally less than 50 ml of fluid in the pericardial space.

Pericardial disease may present as an inflammatory lesion (acute or subacute),

pericardial effusion (with or without cardiac tamponade) or chronic

pericardial constriction.

Acute viral pericarditis is an inflammatory disease that is usually benign and

responds well to anti-inflammatory agents. The majority of cases are

idiopathic, although a viral etiology is also suspected in these patients.

Other infectious agents may also cause pericarditis, as may immune disorders,

drugs, or metabolic diseases of contiguous structures.

An example of the gross pathology follows.

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PATHOLOGY

This is a specimen showing a hemorrhagic pericardial effusion (solid arrow) in

a case where there is also left ventricular hypertrophy (dotted arrow).

Proceed for Case Review

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To Review This Case of

Acute Pericarditis:

The HISTORY is typical for the pain of pericarditis, with a preceding viral

upper respiratory infection.

PHYSICAL SIGNS

a. The GENERAL APPEARANCE reveals an acutely ill man, leaning

forward to relieve his chest pain.

b. The JUGULAR VENOUS PULSE is normal in mean pressure and

wave form.

c. The BLOOD PRESSURE and CAROTID ARTERIAL PULSE

are normal.

d. PRECORDIAL movement is normal.

Proceed

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The ELECTROCARDIOGRAM shows diffuse ST segment

elevation consistent with pericarditis.

The CHEST X RAYS show a mildly enlarged cardiac silhouette with

clear lung fields.

LABORATORY STUDIES include the echocardiogram that shows

a small pericardial effusion.

TREATMENT consists of anti-inflammatory agents.

e. CARDIAC AUSCULTATION reveals a triphasic pericardial friction

rub that is maximum at the lower left sternal edge and varies with

respiration. At the apex, only the systolic component is heard.

f. PULMONARY AUSCULTATION reveals a pleural rub in the left lower

lung fields, reflecting pleural involvement in the pericardial inflammatory

process. In all other lung fields, there are normal vesicular breath sounds.