Catching Acute Pericarditis in the ED: Rubbed the Wrong Way

-Case-
A 28-year-old man comes to the ED with sharp chest pain that began two days ago. It gets worse when he lies flat and improves when sitting up. He had a recent viral illness. Vitals are stable. ECG shows diffuse ST elevations and PR depressions. 

-Evaluation-
Pericarditis is inflammation of the pericardial sac, often triggered by a preceding viral infection but can also be due to autoimmune disease, post-MI syndromes (Dressler’s), uremia, trauma, or malignancy.

  • Classic Symptoms: sharp, pleuritic chest pain that improves with leaning forward
  • Exam: pericardial friction rub is pathognomonic but often missed and difficult to appreciate
  • ECG: diffuse ST elevations and PR depressions (best seen in leads II, aVF, V4-V6); no reciprocal changes
  • CXR: usually normal, but can show enlarged cardiac silhouette if effusion present
  • Echocardiogram: may show a pericardial effusion or signs of tamponade

Diagnosis requires 2+ of the following:

  1. Chest pain characteristic of pericarditis
  2. Pericardial friction rub
  3. Typical ECG changes
  4. Pericardial effusion on imaging

-Management-

  • Stable, uncomplicated cases: NSAIDs (ibuprofen, indomethacin) + colchicine for 3 months
  • Gastroprotection with PPIs when using high-dose NSAIDs
  • Steroids reserved for refractory or autoimmune cases (use cautiously)
  • Admission Criteria: high-risk features include fever >38C, subacute onset, large effusion, immunosuppression, trauma, anticoagulation use, or elevated troponins (suggesting myocarditis)

-Fast Facts-

  • Most cases are viral and self-limiting
  • Troponins may be slightly elevated but should not overshadow ECG findings
  • Look out for pericardial effusion and tamponade as potential complications
  • Colchicine reduces recurrence rates significantly

Chest pain isn’t always a heart attack. Sometimes, it’s the sac around the heart causing the drama. Think pericarditis when chest pain changes with position, and don’t forget to listen closely – there might just be a rub telling you everything you need to know.

Want to learn more? Read our in-depth study guide and listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Imazio M, Gaita F, LeWinter M. Evaluation and treatment of pericarditis: a systematic review. JAMA. 2015;314(14):1498-1506.
  2. Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. Eur Heart J. 2015;36(42):2921-2964.
  3. Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis. N Engl J Med. 2013;369(16):1522-1528.
  4. Permanyer-Miralda G, Sagristà-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol. 1985;56(10):623-630.
  5. Klein AL, Abbara S, Agler DA, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease. J Am Soc Echocardiogr. 2013;26(9):965-1012.e15.
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