A 55-year-old HIV positive man presents to the Emergency Department with sudden onset of chest pain. A more detailed history is taken which reveals that his pain is sharp and improves when he sits forward. Examination shows that he has a temperature of 38.1ºC and his heart rate is 115 beats/min. An ECG is carried out soon after and based on this man’s symptoms, what would be the most likely initial finding?
Low voltage QRS complexes
Concave ST elevation
T wave inversion
Concave ST depression
Absent P wave
This is a typical clinical picture of acute pericarditis. The combination of the pleuritic chest pain which improves upon sitting forward makes this the most likely diagnosis. Typically, widespread ‘saddle-shaped’ or concave ST elevation is seen in the ECG of patients with pericarditis.
What is acute pericarditis?
a condition referring to inflammation of the pericardial sac
How long does acute pericarditis last?
Less than 4-6 weeks, usually one to two weeks
Causes of acute pericarditis
- Infectious: Most commonly viral infections (and in general most common cause of pericarditis). tuberculosis (rare in developed countries but most common cause of pericarditis in endemic areas which are usually developing regions), rarely fungal, rarely parasitic (have been described in HIV positive patients)
- Non infectious:
- metabolic (uraemia, myxedema(disease related to hypothyroidism)
- post-myocardial infarction
- radiotherapy
-connective tissue disease:
systemic lupus erythematosus
rheumatoid arthritis - hypothyroidism
- malignancy
- trauma
- Drugs
Pericarditis post myocardial infarction
early (1-3 days): fibrinous pericarditis. late (weeks to months): autoimmune pericarditis (Dressler’s syndrome)
Which malignancies are more commonly associated with pericarditis
- often secondary to metastatic disease
- lung and breast cancer
Viral infections implicated in pericarditis
Coxsackie, Echovirus, adenovirus, Parvovirus B19, HIV, influenza, Covid, several herpeseviruses, EBV, and CMV
Medications that can lead to pericarditis
- Historically, certain drugs, eg, procainamide, hydralazine, and isoniazid, have been associated with medication-induced SLE, leading to serositis and pericardial involvement manifesting as pericarditis
- More recently, checkpoint inhibitors, eg, ipilimumab and nivolumab, have been increasingly recognized as causes of cardiac toxicity, including myocarditis and pericarditis.
- The 2 most prominent classes of medications are monoclonal antibodies targeting cytotoxic T-lymphocyte–associated antigen 4 (CTLA-4) and programmed cell death 1 (PD-1), along with its ligand PD-L1.
- These therapies have seen numerous advancements in oncology and are likely to be implicated in more cases of cardiac toxicity as their clinical use continues to rise
Features of pericarditis
- chest pain: may be pleuritic. Is often relieved by sitting forwards, worse when laying down
- other symptoms include a non-productive cough, dyspnoea and flu-like symptoms
- pericardial rub
Investigations for pericarditis
- all patients with suspected acute pericarditis should have an ECG and transthoracic echocardiography
- Bloods (Check inflammatory markers and troponin)
ECG changes in pericarditis
- often global/widespread, as opposed to the ‘territories’ seen in ischaemic events
- ‘saddle-shaped’ (concave) ST elevation
- PR depression: most specific ECG marker for pericarditis
Troponin in pericarditis
around 30% of patients may have an elevated troponin - this indicates possible myopericarditis
Management of acute pericarditis (inpatient vs outpatient)
- the majority of patients can be managed as outpatients
- patients who have high-risk features such as fever > 38°C or elevated troponin should be managed as an inpatient
- treat any underlying cause
most patients however will have pericarditis secondary to viral infection, meaning no specific treatment is indicated - strenuous physical activity should be avoided until symptom resolution and normalisation of inflammatory markers
- Medications
Advice for athletes with acute pericarditis
athletes should avoid strenuous exercise for at least 3 months until symptoms have resolved and investigations (CRP, ECG, and echocardiography) have normalised
Medications used in acute pericarditis
- a combination of NSAIDs and colchicine is now generally used for first-line for patients with acute idiopathic or viral pericarditis
- therapy is continued until symptom resolution and normalisation of inflammatory markers (usually 1–2 weeks), followed by a taper of the dose over a further 2–4 weeks
A 67-year-old man presents to the emergency department with sudden onset central chest pain radiating to his left arm. He has a history of hypertension and type 2 diabetes. On examination, he is hypotensive and bradycardic (36/min). His troponin is elevated. Which coronary artery is most likely responsible for his presentation?
Left anterior descending
Right coronary
Left circumflex
Posterior descending
Diagonal branch
Right coronary
What can right coronary artery infarction cause in terms of physiological changes
The right coronary artery (RCA) supplies the atrioventricular (AV) node in the majority of individuals. Infarction in this territory can lead to bradyarrhythmias and hypotension due to impaired conduction through the AV node, as described in this scenario. Inferior myocardial infarctions, typically caused by RCA occlusion, are classically associated with these findings, especially when accompanied by cardiovascular risk factors such as diabetes and hypertension
What can LAD infarction cause in terms of physiological changes
While the left anterior descending (LAD) artery supplies a large portion of the ventricular myocardium and septum, infarction here more commonly results in tachyarrhythmias or heart failure rather than bradycardia and hypotension due to AV nodal dysfunction. LAD infarcts tend to present with anterior ECG changes and less frequently cause conduction block.
What can left circumflex artery infarction cause in terms of physiological changes
The left circumflex artery supplies the lateral wall of the left ventricle; it may occasionally supply part of the posterior wall but rarely causes significant AV nodal involvement unless there is anomalous anatomy or dominance. Circumflex occlusions are less likely to present with profound bradycardia without other features.
What can posterior descending infarction cause in terms of physiological changes
Although the posterior descending artery can arise from either the RCA or circumflex depending on coronary dominance, it is not typically referred to independently as a culprit vessel in acute presentations affecting AV nodal function; its involvement would depend on which main artery gives rise to it.
What can diagonal branch infarction cause in terms of physiological changes
This branch arises from the LAD and supplies part of the anterolateral wall of the left ventricle. Infarction here would not be expected to affect AV nodal conduction significantly or cause pronounced bradycardia/hypotension.
