1. HPI A 35 yo female presents to the ED with chest pain that started this morning. She had cold- like symptoms earlier in the week. She has an important presentation at work this afternoon about her recent meeting with investors in Japan and wants to know how long it is going to take to find out what is wrong. What else would you like to ask?

2. HPI Onset Setting Severity Quality Location, Radiation Duration Frequency Aggravating Factors Alleviating Factors Associated Symptoms

3. HPI Onset - Sudden, acute Setting - Started when she woke up this morning Severity - 10/10! Quality - Sharp Location, Radiation - Left-sided, radiating to left shoulder Duration - 2 hours Frequency - No previous episodes Aggravating Factors - Inspiration, lying down, coughing, swallowing Alleviating Factors - Sitting up and leaning forward Associated Symptoms - palpitations What else do you want to know?

4. PMH Medical Hx: C-section (2009) Family Hx: non-contributory, no family history of heart disease or bleeding disorders Social: Married with 2 children, works in finance, one glass of wine per week, denies tobacco and illicit drug use What is your differential diagnosis?

5. DDx Acute MI Pulmonary Embolism Pneumothorax Pneumonia Pericarditis Asthma GERD Anxiety What do you want to do next?

6. Physical Exam Vitals: BP 120/80, T 99.0, HR 80, RR 20 General: Patient is sitting on the edge of the hospital bed leaning forward HEENT, Abdominal, Neuro, and Psych Exams: wnl CV: RRR, no murmurs, rub heard at left lower sternal border at the end of expiration Respiratory: shallow breaths, able to speak in full sentences, lungs clear to auscultation bilaterally What labs do you want to order and why?

7. Lab Tests Cardiac Markers – rule out MI CBC – evaluate for infection, inflammation Electrolytes – increased risk of arrhythmias in pericarditis CRP, ESR – evaluate for inflammation D-dimer – rule out PE (low suspicion) CXR – evaluate for pneumonia, pneumothorax, PE, effusion ECG – rule out MI, pericarditis

8. Lab Results Troponin I - < 10 μg/L CBC, electrolytes – normal CRP – 16 mg/L ESR – 25 mm/h D-Dimer – 100 ng/mL

9. ECG What’s your impression of the ECG?

10. Widespread ST elevation without reciprocal depression PR depression in lead II

11. Chest X-Ray Note the cardiomegaly How can we further evaluate this enlarged heart?

12. Cardiac Echo shows pericardial effusion RV – right ventricle LV – left ventricle LA – left atrium Ao – aorta PE – pericardial effusion

13. Chest CT – Thick arrow – pericardial effusion – Thin arrow – pleural effusion

14. Overview of Acute Pericarditis Inflammation of the pericardial sac accompanied by pericardial effusion “Bread and Butter Heart”

15. Histology of Acute Pericarditis – PMNs adhering to the epicardium

16. Overview of Acute Pericarditis Many possible causes, including: – Idiopathic (usu. post-viral) – Infection (viral, bacterial, fungal) – Acute MI – Dressler’s syndrome – SLE – Drug-induced (procainamide, hydralazine) – Amyloidosis – Radiation – Post-surgery

17. Hallmarks of Acute Pericarditis Symptoms: – Chest pain Pleuritic, associated with breathing Positional  relieved by sitting up and leaning forward – Dyspnea – Palpitations – +/- fever, non-productive cough

18. Hallmarks of Acute Pericarditis ECG Changes – diffuse ST-segment elevation and PR depression Physical Exam Findings: – Friction rub – Pulsus paradoxus – Distant Heart Sounds

19. Pericardial Friction Rub Pathognomonic for acute pericarditis Heard best at left lower sternal edge with patient sitting up, leaning forward, & exhaling High-pitched, grating sound with 3 components http://www.youtube.com/watch?v=J1R8Oxgq hfk http://www.youtube.com/watch?v=J1R8Oxgq hfk

20. Pulsus Paradoxus > 10 mmHg fall in systolic blood pressure during inspiration Seen with cardiac tamponade, asthma, pericarditis

21. Treatment NSAIDs, medium to high doses – 1 st line Corticosteroids – if NSAIDs fail or are contraindicated, recurrent pericarditis Colchicine – prevents recurrent pericarditis Pericardiocentesis – for large effusion with hemodynamic compromise, cardiac tamponade, or diagnostic purposes Pericardiectomy – for persistent constrictive pericarditis

22. Pearls Acute Pericarditis Key Findings (need 2 of 4 for diagnosis): – Pleuritic chest pain improved by leaning forward – Pericardial friction rub – Widespread ST elevation on ECG – Pericardial effusion

23. Summary The patient was diagnosed with acute pericarditis and started on NSAID therapy She continued to be in stable condition and was discharged from the ED with instructions to follow-up with her PCP She was told to expect her symptoms to resolve in 2 weeks to 3 months