Acute Pericarditis

June 1, 2004

A 35-year-old woman (gravida 3, para 2) presented at 25 weeks’ gestation with a 24-hour history of continuous, pressure-like, retrosternal chest pain, radiating only to the back. The pain worsened when she lay down, took deep inspirations, or coughed; it diminished when she leaned forward. The patient had no significant medical history and was not taking any medications; she denied fever and illicit drug use.

A 35-year-old woman (gravida 3, para 2) presented at 25 weeks’ gestation with a 24-hour history of continuous, pressure-like, retrosternal chest pain, radiating only to the back. The pain worsened when she lay down, took deep inspirations, or coughed; it diminished when she leaned forward. The patient had no significant medical history and was not taking any medications; she denied fever and illicit drug use. Heart rate was 91 beats per minute and regular, and all peripheral pulses were normal. Blood pressure was 122/79 mm Hg; respiration rate, 20 breaths per minute; and temperature, 37.1°C (98.7°F). Jugular venous pressure was normal. Heart sounds were normal, with no additional sounds. Lungs were clear. Examination of lower extremities revealed no edema or signs of venous thrombosis. White blood cell count was 10,000/μL, without a leftward shift. Erythrocyte sedimentation rate was 41 mm/h. D-dimer assay results were within normal limits. A chest radiograph showed no abnormality. Cardiac enzyme levels were normal. A ventilation-perfusion scan was normal. An echocardiogram showed normal chamber sizes, left ventricular function, and valves and no pericardial effusion or evidence of right ventricular dysfunction. The first ECG obtained after 24 hours of continuous chest pains showed no clear diagnostic change (A). The second ECG performed 6 hours later showed changes suggestive of acute pericarditis (B). Nazim Uddin Azam Khan, MD, Richard Alan Reinhart, MD, and Assad Movahed, MD, of Greenville, NC, write that ECG changes in acute pericarditis consist of diffuse ST-segment elevations with upward concavity, except in leads aVR and V1, and PR-segment deviation opposite to the P-wave axis. While ECG changes may take up to 24 hours to develop, it is rare for the changes to develop more than 24 hours after the onset of pain, as in this case. The cause of this patient’s pericarditis could not be determined. All laboratory investigations were normal. Relief of symptoms and management of causative factors are the mainstay of therapy. NSAIDs are the treatment of choice in acute pericarditis. Ibuprofen is associated with the least adverse effects.1 The patient was not treated with NSAIDs because of her pregnancy. She was given intravenous morphine for pain; further medications were not necessary. Her symptoms subsided rapidly without recurrence. She was discharged within 24 hours. The patient delivered her infant at term without complications. At 1-year follow-up, she was in good health.