Pleuritic Chest Pain in a Young Woman

A 28-year-old woman with no medical history comes to the emergency department (ED) complaining of sudden onset of midsternal pleuritic chest pain that started one day ago and is getting worse. The pain radiates to the left scapula and is worse with inspiration. She denies fever, cough, or being out of breath but has a runny nose. A coworker recently had a bad cold with a cough. There has been no heavy lifting.

Findings of physical examination include normal vital signs, a tender chest, and normal heart and breath sounds

A chest x-ray is read as normal. Her ECG tracing is shown below.

• What is your ECG read?  

• What is the most likely diagnosis?

Answers and Discussion >>>

Answers

What are the findings?  

• There is diffuse ST elevation with PR depression as well as multifocal P-waves

What is the most likely diagnosis?

• Pericarditis

Discussion

This patient had a strong history and ECG presentation for pericarditis with pain being worse when supine, but she also had some atypical features including a tender chest and pain that was aggravated by the act of sitting up (although it was better once seated). A rub was not heard, but this is common. (Decent recordings are available on Youtube.)

Pericarditis classically causes pleuritic chest pain that is worse when supine. Pulmonary embolism must be considered as it can also cause positional pain, though not usually the same EKG changes. In this case results of a d-dimer test were negative so CT was not ordered to avoid radiation exposure.

The physical examination is usually normal in pericarditis with a rub heard in only a minority of cases. To improve chances of hearing a rub, listen to the heart in full exhalation with the patient leaning forward.

ECG changes at presentation are usually diffuse concave-up ST elevation and PR depression, except in lead avR where PR elevation is pathognomonic for pericarditis. There are actually 4 stages of ECG changes (see table below for stages 2-4). Troponin and inflammatory markers should also be ordered. This patient was noted to have multifocal P-waves, which is unusual and was thought to be the result of atrial irritability.

Most cases of pericarditis end up being idiopathic. Other causes should be considered and investigated selectively depending on known prior medical history and risk factors. See table below for causes of pericarditis.

Treatment for idiopathic pericarditis should include colchicine combined with an NSAID. Steroids should generally be avoided as initial therapy as they increase the risk of relapse. If a primary cause is suspected or identified, therapy should be tailored appropriately. Most patients with pericarditis and stable vital signs can be managed as outpatients.  If vital signs are abnormal, there is a large pericardial effusion, the patient is on blood thinners, or the troponin level is elevated, admission to the hospital should be seriously considered (see Table below for details).

Table.

PERICARDITIS from Quick Essentials Emergency Medicine 1-minute Consult pocketbook

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