Presenting Complaint: 

Javier presents with sudden-onset chest pain.

Quote: “I’ve noticed having really bad chest pain for the past few hours.”

HPC and symptoms (SOCRATES):

Site: Central chest pain.

“The pain feels the worse in the middle of my chest.”

Onset: The pain started suddenly four to six hours ago.

“The pain came on suddenly and has lasted for around 5 hours.”

Characteristics: Sharp, stabbing pain.

“It is really sharp, like someone is stabbing me in my chest.”

Radiation: Mainly around the centre of the chest but sometimes spreads to the left shoulder.

“Mostly it is around the middle of my chest but occasionally I get some pain in my left shoulder but this pain goes away.”

Associated Symptoms/CardioResp System Review:

No dizziness, feeling faint or palpitations before, during or after the chest pain spells.

No nausea or vomiting or sweating with the chest pain.

No shortness of breath, cough, leg pain or swelling.

“No other symptoms apart from the chest pain.”

Exacerbating/relieving factors: You feel the pain is worse when you breathe in and lie down flat but the pain is better when you lean forward.

“I tend to get the pain worse when I breathe in and lie down on my back, but if I lean forward the pain lessens and is manageable.”

Systems Review:

• Recent illness: Had the flu one week ago.
• B-Symptoms: No fever, lethargy, anorexia, weight loss or night sweats.
• GI and Urinary Symptoms: No changes in bowel and bladder habits, no nausea or vomiting.
• Cardio Symptoms: No palpitations or dizziness.
• Respiratory Symptoms: You have no shortness of breath, cough or breathing difficulty.
• Neuro Symptoms: No changes in vision, smell or taste. No sensorimotor deficit, ataxia or balance and coordination issues. No seizures or loss of consciousness.

Otherwise well, no other problems.

Past Medical History:

• Type two diabetes mellitus.
• No known hospital admissions or past surgeries.
• No previous known history of cardiovascular disease or chest pain.

Drug History:

• Metformin and Empagliflozin.
• No herbal supplements or alternative therapies.

Allergies:

• Allergic to penicillin. Had an episode of anaphylaxis when treated with penicillin for cellulitis when he was young. 

Family History:

• Mother: Type 1 diabetes mellitus.
• Father: Bowel cancer.

Social History:

• Smoking: Non-smoker.
• Occupation: Banker.
• Alcohol: 12 units per week.
• No travel history.
• Lives at home with family.
• Activities of Daily Living & Hobbies: Football and Tennis.

ICE:

• Ideas: “I’m thinking this could be a heart attack.”
• Concerns: “I am worried that this pain will not go away.”
• Expectations:  “I’d like some medication and treatment as soon as possible.”

Observations:

• HR:  92 bpm
• BP: 120/75
• SpO2: 98%
• Temperature: 36.6℃
• Respiratory Rate: 18 breaths per min
• GCS: 15/15

NEWS score: 1

Physical Examination:

General inspection:

• Visibly in pain.

Inspection

• No peripheral oedema.
• No peripheral stigmata of cardiovascular disease, warm and well perfused, CRT< 2 seconds.

Face and neck

• JVP not visible.
• No cyanosis or pallor present in the face.

Chest

• No scars or pulsations visible.

Palpation

• Apex beat non-displaced.
• No heaves or thrills.
• All pulses present (radial, brachial, carotid).
• Radial pulse regular, strong and bounding.
• No radio-radial delay.
• No collapsing pulse.

Auscultation

• Heart sounds: S1 + S2.
• You hear a scratchy, crunching sound, best heard with the patient leaning forward, with end expiration, and at the left sternal border. This is still audible when the patient is asked to hold their breath.
• Chest clear.
• Nil other murmurs.
• No carotid bruits.

Examiner Questions:

1. Describe the findings on this ECG

Answer:

• Mild tachycardia approx 100 bpm
• Regular rhythm
• Nil axis deviation
• Diffuse concave ST-elevation in precordial and limb leads
• Widespread PR depression
• Reciprocal ST depression in aVR
• Spodick’s sign (downsloping T-P segment) seen best in leads II and V4-5

2. What is the most likely diagnosis and what are your differential diagnoses?

• Acute Pericarditis – This is the most likely differential. There is sudden-onset, sharp, pleuritic chest pain which is positional and alleviated by leaning forward, and exacerbated when lying supine. There is a lack of usual MI-associated symptoms such as nausea, sweating, and characteristic ‘crushing’ or ‘squeezing’ pain. The patient reports a recent history of viral infection, which is the most common risk factor for pericarditis in a young patient in the UK, and there is no significant cardiac, smoking, or family history. Finally, on examination a characteristic pericardial friction rub is heard. This was still heard on holding breath, and is therefore unlikely to be a pleural friction rub.

• It is imperative to look for signs of cardiac tamponade, a potentially life-threatening complication of pericarditis. Pericarditis is inflammation of the pericardium, which can lead to fluid collecting in the pericardial space (pericardial effusion). If this continues to increase in size and pressure, it can impair ventricular filling and reduce cardiac output, leading to cardiac tamponade. 
• Beck’s triad can be used to assess clinical signs of tamponade:
  • Hypotension
  • Quiet/muffled heart sounds
  • Raised JVP

N.B. Criteria for Acute Pericarditis (new onset <4-6 weeks)

• At least 2/4 criteria:

1. Characteristic pericarditic chest pain: typically sharp, pleuritic; relieved by sitting forwards and worsened by lying flat

2. Pericardial friction rub on auscultation

3. New widespread diffuse concave upwards ST elevation and/or PR depression on ECG.

4. Pericardial effusion (new or worsening).

Additional supporting findings include:

• Elevated inflammatory markers (i.e., C-reactive protein, erythrocyte sedimentation rate, white blood cell count).
• Evidence of pericardial thickening/inflammation on advanced imaging techniques (i.e., cardiac computed tomography or magnetic resonance imaging).

Other possible but less likely diagnoses:

• Myocardial Infarction – With any presentation of central chest pain MI should be considered and urgently ruled out. With a myocardial infarction, typically the patient is older and may have cardiac risk factors such as diabetes, smoking, hyperlipidaemia and previous cardiovascular disease e.g. angina. Alongside the pain, patients can report episodes of nausea, vomiting and sweating. While MI certainly needs to be ruled out urgently, the young age and lack of cardiac risk factors, history of viral infection and key examination findings point towards pericarditis over MI. Further investigation with ECG, echocardiography and troponin may help distinguish the two.
• Pulmonary Embolism – PE typically presents with acute-onset shortness of breath and pleuritic chest pain, and so will need to be ruled out urgently. Patients with PE may have pro-thrombotic risk factors in the history, such as long haul flight, surgery, immobility, some medications, cancer or thrombophilia. The lack of risk factors in this case, and lack of SOB points away from PE, however investigation with D-dimer +/- CTPA may be warranted to rule out.
• Pneumonia – Presents with chest pain that can be pleuritic/worsens when the patient breathes. Pneumonia would likely be associated with a cough that may be productive, SOB, and fever. The history makes an infective picture less likely with apyrexia on examination. Lack of SOB and cough makes pneumonia unlikely.
• Gastro oesophageal reflux syndrome (GORD) –  In GORD the reflux of gastric contents into the oesophagus may cause retrosternal burning pain, which may be worse lying supine as well. In addition patients may report worsening after eating +/- nausea and vomiting with the pain. Overall, GORD is unlikely due to the lack of reflux/gastrointestinal symptoms in this patient and the lack of risk factors e.g. older age or obesity.

3. What investigations would you consider in this patient?

• ECG (as above): Pericarditis typically has the characteristic ECG findings of global saddle-shaped concave ST-Elevation and PR-Depression (may be inverted in AVR and V1). This may evolve over several days with development of T-wave flattening and inversion before returning to normal. 
• Bloods: Troponin should be ordered in any presentation of chest pain to exclude ischaemic heart disease/MI, however this may be elevated in 35-50% of pericarditis patients, indicating possible involvement of the myocardium (myopericarditis). This is neither very sensitive nor specific and may be of limited help.
  • Inflammatory markers e.g. FBC, CRP, ESR are often raised on presentation, and may be useful in monitoring response to treatment, or if infective aetiology is suspected. 
  • U+Es and LFTs for baseline. Significantly elevated urea can cause pericarditis.
  • D-dimer may be used to exclude PE.
• Transthoracic echocardiogram (TTE): Echo is a key investigation in pericarditis. It can detect pericardial thickening and hyperechogenicity, pericardial effusions (>60% patients, one of the diagnostic criteria for pericarditis), and can help differentiate between pericarditis and acute coronary syndromes by detecting ventricular wall motion abnormalities. There are important limitations to echo, such as poor acoustic window in obese patients, and high operator dependence.
• Chest X-ray: To rule out any other causes of chest pain e.g. rib fracture/trauma, pneumonia, pneumothorax. Usually normal unless large-volume pericardial effusion present (>300ml).
• Other investigations to consider:
  • Viral Screen: if suspecting viral cause of pericarditis
  • Cardiac MRI/CT: To further evaluate pericarditis with multi-modal imaging, following echo first-line. Can characterise pericardial thickening, calcification, myocardial involvement and concomitant disease. 
  • CTPA: If PE is strongly suspected 

4. Given the suspected diagnosis of acute pericarditis, how do you manage this patient?

• NSAIDs (e.g. aspirin, ibuprofen) and colchicine (to prevent early recurrence) are first-line. 
• PPIs e.g. omeprazole co-prescribed to help prevent development of gastric/duodenal ulcers from high dose NSAIDs. 
• Corticosteroids can be considered as a second-line treatment if NSAIDs fail/are contraindicated.

• If there is suspicion of an underlying cause of pericarditis e.g. systemic inflammatory condition, TB, uraemia etc, investigating and treating this is a priority. Other rare aetiologies include paraneoplastic, drug-related and post-radiotherapy.
• Admission vs ambulatory management is based on risk stratification and suspicion of underlying aetiology (other than viral or idiopathic).
• If signs of cardiac tamponade are present, seek help immediately from a senior colleague. This is a life-threatening complication and will require likely pericardiocentesis.