Chest Pain in a Healthy 43-Year-Old Man

September 1, 2005
Ronald N. Rubin, MD

A 43-year-old man presents to the emergency department with worsening substernal chest pain that has developed over several hours. He describes the pain as dull and oppressive; it radiates to the left shoulder and jaw and worsens on inspiration and with recumbency. It is not associated with nausea, dizziness, or diaphoresis. He is given nitroglycerin, morphine, hydromorphone, and meperidine parenterally, but none of these relieve the pain.

A 43-year-old man presents to the emergency department with worsening substernal chest pain that has developed over several hours. He describes the pain as dull and oppressive; it radiates to the left shoulder and jaw and worsens on inspiration and with recumbency. It is not associated with nausea, dizziness, or diaphoresis. He is given nitroglycerin, morphine, hydromorphone, and meperidine parenterally, but none of these relieve the pain.

HISTORY

The patient was previously healthy. He has no history of hypertension, hypercholesterolemia, diabetes, or other serious disorders, and he does not take any long-term medications. He has no history of recent viral infections, and he does not smoke or drink alcohol to excess. There is no family history of heart disease.

PHYSICAL EXAMINATION

The patient is in significant distress and has difficulty in speaking because of the pleuritic nature of his pain. Blood pressure is 120/95 mm Hg; heart rate is 104 beats per minute. The pain is not reproducible by palpation. There is no jugular venous distention or hepatojugular reflux. A loud, scratchy pericardial friction rub is audible over the left sternal border; the rub is most prominent when the patient leans forward.

LABORATORY AND IMAGING RESULTS

The hemogram, chemistry panel results, cardiac enzyme levels, ECG, echocardiogram, and chest radiograph are all normal.

CORRECT ANSWER: B

This patient's findings are most consistent with acute idiopathic pericarditis.

Diagnosis of pericarditis. This diagnosis can usually be made clinically, based on the history taking and physical findings. A clinical diagnosis requires that at least 2 of the following 3 findings be present:

•Chest pain, which most typically is substernal and pleuritic; other typical features of the pain include worsening with recumbency and easing on leaning forward.

•Pericardial friction rub.

•Diffuse upsloping (concave) ST-segment elevations, usually less than 5 mm and seen diffusely in both the precordial and the limb leads (an indication that more than one coronary vascular territory is involved--something that is unusual in acute MI). In addition, PR-segment depressions are often seen (the atrial counterpart of ST-segment elevations).

Diagnostic testing of a patient with suspected acute idiopathic pericarditis includes:

•History taking and physical examination that focus on causes of pericarditis and evidence of cardiac tamponade.

•ECG (to look for evidence of myocardial injury, such as myocarditis).

•Chest radiograph (to check for recent cardiac enlargement).

•Echocardiogram--a good screening tool for structural heart disease in general and pericardial effusion in particular.

An underlying cause of acute pericarditis is identified in about 16% of patients. Such causes include neoplasia, tuberculosis, nontuberculous infection, rheumatic disease, and uremia. However, in most patients who present with acute pericarditis, an identifiable cause of the condition is not found.1,2 Patients in whom no cause is identified are presumed to have viral or autoimmune pericarditis.

Management. Uncomplicated pericarditis can be managed on an outpatient basis, with closely scheduled follow-up visits. Administration of aspirin or NSAIDs usually results in prompt relief of pain, although there is no evidence that anti-inflammatory medications prevent tamponade, constriction, or recurrent pericarditis.3 Colchicine has also been used effectively, alone or with concomitant NSAIDs.4 Outpatient therapy with NSAIDs or aspirin is effective in 87% of patients and is the therapy of choice for patients whose illness has no high-risk features.5 High-risk features that require hospitalization and further evaluation include:

•Pericarditis associated with acute trauma.

•High fever and leukocytosis.

•Presence of a large pericardial effusion.

•Physiologic evidence of pericardial tamponade.

•Immunosuppressed state.

•Failure to respond to NSAID therapy within a few days.

Our patient has none of these features. Thus, choice B is most appropriate here. Failure to respond to NSAIDs would suggest that something other than viral or idiopathic pericarditis is the cause of his pain.

"Rule out MI" (choice A) may be the most frequently used protocol in emergency departments and hospitals today. However, this patient is healthy, is relatively young, and has norisk factors for MI. His pain syndrome has features that point to a pericardial origin (pleuritic component, postural changes). His ECG does not suggest ischemia, and his cardiac enzyme levels are normal. In addition, a friction rub is present. Thus, an evolving MI is very unlikely here.

Breast cancer (in women), lung cancer, and hematologic malignancy are the most common malignant causes of pericardial disease. This patient's age, normal chest radiograph, and normal hemogram make malignant disease unlikely. Thus, any further evaluation for occult malignancy (choice C) can be deferred pending presumed resolution of his pericarditis.

Pericardial stripping (choice D) is an aggressive therapy used for chronic constrictive pericarditis, which can be identified using echocardiography. At the present time, this patient has no evidence of constrictive pericarditis.

Outcome of this case. A course of NSAIDs was initiated, and by the next morning, the patient had experienced significant relief of symptoms. The pain slowly abated and was gone by day 5. He never experienced cardiac symptoms, such as dyspnea on exertion or paroxysmal nocturnal dyspnea. By day 8, he was asymptomatic, no friction rub was audible, and his ECG was normal. *

References:

REFERENCES:

1.

Zayas R, Anguita M, Torres F, et al.Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis.

Am J Cardiol.

1995;75:378-382.

2.

Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients.

Am J Cardiol.

1985;56:623-630.

3.

Lange RA, Hillis LD. Acute pericarditis.

N Engl J Med

. 2004;351:2195-2202.

4.

Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy.

J Am Coll Cardiol.

2004;43:1042-1046.

5.

Maisch B, Ristic A, Pankuweit S. Intrapericardial treatment of autoreactive pericardial effusion with triamcinolone; the way to avoid side effects of systemic corticosteroid therapy.

Eur Heart J.

2002;23:1503-1508.

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