Pericarditis differential diagnosis: Difference between revisions
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* The EKG of pericarditis shows [[ST elevation]] that does not necessarily follow the anatomic distribution of a single coronary artery. | * The EKG of pericarditis shows [[ST elevation]] that does not necessarily follow the anatomic distribution of a single coronary artery. | ||
These differentiating features are summarized in the table below <ref name=mk /> | |||
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| Sudden or chronically worsening pain that can come and go in [[paroxysm]]s or it can last for hours before the patient decides to come to the ER | | Sudden or chronically worsening pain that can come and go in [[paroxysm]]s or it can last for hours before the patient decides to come to the ER | ||
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==Chest Pain Following Myocardial Infarction == | |||
It should be noted that acute MI can also be associated with the development of pericarditis. In a patient with recurrent chest pain following acute MI, one is often left wondering whether the chest pain is due to recurrent pain due to reocclusion of the culprit artery, or if it is due to the early development of pericarditis, or if it occurs later, if it is due to Dressler's syndrome. | |||
===Clinical presentation=== | |||
Substernal or left precordial [[pleuritic]] [[Chest pain]] with radiation to the trapezius ridge (the bottom portion of [[scapula]] on the back), which is relieved by sitting up and bending forward and worsened by lying down (recumbent or [[supine]] position) or inspiration (taking a breath in), is the characteristic pain of pericarditis.<ref name=mk>American College of Physicians (ACP). Medical Knowledge Self-Assessment Program (MKSAP-15): Cardiovascular Medicine. "Pericardial disease." p. 64. ISBN 978-934465-28-8 [http://www.acponline.org/products_services/mksap/15/complete.htm]</ref> The pain, may resemble the pain of [[angina pectoris]] or heart attack but differs in that pain changes by body positions, as opposed to heart attack pain that is pressure-like, and constant with radiation to the left arm and/or the jaw. Other symptoms of pericarditis may include dry [[cough]], [[fever]], fatigue, and [[anxiety]]. Due to similarity to myocardial infarction (heart attack) pain, pericarditis can be misdiagnosed as an acute [[myocardial infarction]] (a heart attack) solely based on the clinical data and so extreme suspicion on the part of the diagnostician is required. Ironically an acute [[myocardial infarction]] (heart attack) can also cause pericarditis, but often the presenting symptoms vary enough to warrant a diagnosis. | |||
Revision as of 12:55, 17 July 2011
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]
For a full discussion of the differential diagnosis of chest pain click here
For an expert algorithm that aids in the diagnosis of the cause of chest pain click here
Differentiating Pericarditis from other Conditions
Several conditions, including life threatening conditions such as myocardial infarction, aortic dissection and pulmonary embolism produce signs and symptoms that are similar to those produced by pericarditis. Although the following features are not 100% sensitive and/or specific in distinguishing the different causes of chest pain, they are useful guides:
- Pain along the trapezius ridge(s), is very characteristic of pericarditis. The pain of myocardial infarction tends to involve the anterior precordium with radiation to the left arm.
- Unlike cardiac ischemia, the pain of pericarditis often lasts longer, and is unresponsive to vasodilator therapy.
- Ischemic chest pain is often described as a sense of "heaviness" whereas the pain of pericarditis is often pleuritic in nature.
- Ischemic chest pain is generally not positional in nature whereas the pain of pericarditis may be relieved by sitting forward.
- The EKG of pericarditis shows PR segment depression while the EKG of myocardial infarction does not (unless there is atrial infarction).
- The EKG of pericarditis shows ST elevation that does not necessarily follow the anatomic distribution of a single coronary artery.
These differentiating features are summarized in the table below [1]
| Characteristic/Parameter | Pericarditis | Myocardial infarction |
|---|---|---|
| Pain description | Sharp, pleuritic, retro-sternal (under the sternum) or left precordial (left chest) pain | Crushing, pressure-like, heavy pain. Described as "elephant on the chest." |
| Radiation | Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation. | Pain radiates to the jaw, or the left or arm, or does not radiate. |
| Exertion | Does not change the pain | Can increase the pain |
| Position | Pain is worse supine or upon inspiration (breathing in) | Not positional |
| Onset/duration | Sudden pain, that lasts for hours or sometimes days before a patient comes to the ER | Sudden or chronically worsening pain that can come and go in paroxysms or it can last for hours before the patient decides to come to the ER |
Chest Pain Following Myocardial Infarction
It should be noted that acute MI can also be associated with the development of pericarditis. In a patient with recurrent chest pain following acute MI, one is often left wondering whether the chest pain is due to recurrent pain due to reocclusion of the culprit artery, or if it is due to the early development of pericarditis, or if it occurs later, if it is due to Dressler's syndrome.
Clinical presentation
Substernal or left precordial pleuritic Chest pain with radiation to the trapezius ridge (the bottom portion of scapula on the back), which is relieved by sitting up and bending forward and worsened by lying down (recumbent or supine position) or inspiration (taking a breath in), is the characteristic pain of pericarditis.[1] The pain, may resemble the pain of angina pectoris or heart attack but differs in that pain changes by body positions, as opposed to heart attack pain that is pressure-like, and constant with radiation to the left arm and/or the jaw. Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety. Due to similarity to myocardial infarction (heart attack) pain, pericarditis can be misdiagnosed as an acute myocardial infarction (a heart attack) solely based on the clinical data and so extreme suspicion on the part of the diagnostician is required. Ironically an acute myocardial infarction (heart attack) can also cause pericarditis, but often the presenting symptoms vary enough to warrant a diagnosis.