"Pericarditis" strikes again

Written by Pendell Meyers

A man in his late 40s with several ACS risk factors presented with a chief complaint of chest pain.  Several hours prior to presentation, while driving his truck, he started experiencing new central chest pain, without radiation, aggravating/alleviating factors, or other associated symptoms. On review of systems the patient reported back pain for approximately 1 week which he was treating with NSAIDs with minimal relief. On exam the patient was well appearing, with normal vitals signs other than BP 155/82, no murmurs or rubs, normal pulses, no reproducible chest pain.

Here is his triage ECG:

What do you think?

Sinus rhythm
Normal QRS morphology
Diffuse STE, including leads V2-V6, I, II, III, aVF (with obligatory reciprocal STD in aVR)
Perhaps a tiny bit of PR depression (up to 0.8 mm has been described in normal subjects)

Overall impression: In my opinion and experience, this ECG most likely represents a normal baseline ECG, but with a small chance of pericarditis instead. I do not believe there is any finding here suggestive of OMI.

I texted this to Dr. Smith without any information, and this was his reply: 
"This could be pericarditis but probably is normal variant."

The treating clinicians were worried about the ST elevations and called cardiology for emergent PCI consult. The cardiologists felt that the ECG did not represent ACS, and thought it was more likely pericarditis, so they did not take him to the cath lab.

His first troponin T then resulted elevated at 0.19 ng/mL.

A repeat ECG was performed and cardiology was re-consulted:
Roughly unchanged.

With the troponin elevated and ongoing pain, cardiology now decided to take him to the lab.

They found non-obstructive CAD, with only a 20% stenosis of OM2 and 10% RCA. No acute culprit.

He was admitted to cardiology.

Here is a quote from his initial cardiology admission note (after cath was done showing no acute culprit):

"...chest pain, non-radiating, pleuritic in nature, relieved by sitting forward"

"Plan: likely myocarditis"

Colchicine was ordered and the patient received the first dose in the afternoon.

Troponins gradually trended down from 0.19 ng/mL.

The next morning the patient went for his routine echocardiogram, where the operator noticed a dilated aortic root at 5.47 cm with severe aortic insufficiency. The team was notified and they ordered a stat aortagram which showed type A aortic dissection from the aortic valve to the iliacs.

Aortic Root Dissection

The aorta was emergently repaired, and the patient had a complex course (including a saddle PE and subsequent GI bleed!) in the ICU but survived with excellent function.

Not surprisingly the cardiology HPI changed yet again in the next note following diagnosis of the aortic dissection:

"...chest pain that began acutely while was attempting to park his truck, described as dull pain which radiates to the back, without exacerbating or alleviating factors..."

Here is his ECG several days after diagnosis:
Again, normal variant STE
Pericarditis would have its own typical evolution, as would acute MI.

The patient returned one month later for an unrelated problem:

Learning Points:

It seems likely to me that the notion of "pericarditis" delayed or completely prevented diagnosis of aortic dissection in this young man. As we have described multiple times on this blog, false positive "pericarditis" kills by distracting the clinician from actual emergencies including OMI, dissection, PE, and others.

The vast majority of cases with chest pain diffuse ST Elevation are due to Normal Variant ST Elevation, NOT to pericarditis. 

You diagnose pericarditis at your peril!  Acute MI is frequently misdiagnosed as pericarditis.  Patients with pulmonary embolism or aortic dissection who have normal variant ST elevation are at high risk of being diagnosed with pericarditis when what they have is far more serious!!  Pericarditis is a diagnosis of EXCLUSION.

On the ECG of pericarditis:
--There should be marked PR depression
--There should be flat ST elevation with low T-wave to ST segment ratio. 
--There should be no reciprocal ST depression anywhere except aVR. 
--And there should be confirmatory evidence, and evidence of EXCLUSION of other serious pathology.

See this case, also written by Pendell Meyers when he was a medical student:

31 Year Old Male with RUQ Pain and a History of Pericarditis. Submitted by a Med Student, with Great Commentary on Bias!  (normal variant misdiagosed as pericarditis)

Other cases:

Palpitations and Chest Tightness: Should You Activate the Cath Lab (or Give Thrombolytics)? (normal variant, not pericarditis)

A Young Man with Sharp Chest pain
 (normal variant, not pericarditis)

Source: hqmeded ecg

"Pericarditis" strikes again