Cardiovascular · Year 1 · from Cardiovascular
Case 1: Acute Pericarditis - Classic Presentation
Clinical Image
Source: Wikimedia Commons - Pericarditis ECG - CC BY-SA 3.0
Patient Presentation
A 24-year-old man presents to the emergency department with sharp chest pain that began yesterday. The pain is worse when he lies flat and when he takes a deep breath, and improves when he sits up and leans forward. He had a "cold" with fever, sore throat, and myalgias about 10 days ago that has since resolved. He has no significant medical history and takes no medications.
Demographics
- Age: 24 years
- Sex: Male
- Past Medical History: None
- Medications: None
- Social History: College student, no smoking, occasional alcohol
Chief Complaint
Sharp chest pain worse with inspiration and lying flat, better with sitting forward
Physical Examination
- Temperature: 37.8°C (low-grade fever)
- Blood pressure: 118/74 mmHg
- Heart rate: 92 bpm
- Respiratory rate: 18/min
- Oxygen saturation: 99% on room air
- General: Appears uncomfortable, sitting forward
- Cardiovascular: Three-component pericardial friction rub best heard at left lower sternal border with patient leaning forward at end-expiration
- Respiratory: Clear to auscultation
- No JVD, no peripheral edema
Workup
- ECG: Diffuse ST elevation with upward concavity ("saddle-shaped"), PR depression in leads II, III, aVF and V2-V6; PR elevation in aVR
- Troponin: 0.08 ng/mL (mildly elevated - myopericarditis)
- CRP: 8.2 mg/dL (elevated)
- ESR: 45 mm/hr (elevated)
- WBC: 11,200/μL
- Echocardiography: Small circumferential pericardial effusion (5 mm), normal LV function
- Chest X-ray: Normal cardiac silhouette
Diagnosis
Acute Viral/Idiopathic Pericarditis with Mild Myopericarditis
Treatment
- NSAIDs (ibuprofen 600 mg TID or aspirin 750-1000 mg TID) for 1-2 weeks
- Colchicine 0.5 mg BID for 3 months (reduces recurrence by ~50%)
- Activity restriction until symptoms resolve and inflammatory markers normalize
- Gastric protection with PPI during NSAID therapy
- Avoid corticosteroids (increase recurrence risk)
- Follow-up echocardiogram if symptoms persist
- Return precautions for worsening symptoms, dyspnea, or syncope
Physiological Principles Demonstrated
- Pericardial pain characteristics: Pain is pleuritic (worse with inspiration) because the inflamed pericardium moves with respiration. Improvement with leaning forward reduces pericardial stretch.
- Friction rub mechanism: The three-component rub corresponds to atrial systole, ventricular systole, and early ventricular diastole when inflamed pericardial layers rub against each other.
- ECG evolution: Stage 1 (diffuse ST elevation, PR depression) reflects epicardial inflammation. Unlike STEMI, changes are diffuse and do not follow coronary territories.
- Viral etiology predominance: In developed countries, most cases are idiopathic or presumed viral; extensive workup is not indicated in uncomplicated first presentations.