Diagnosis: Acute Pericarditis

Review of the patient's ECG demonstrated diffuse ST-elevations and questionable PR-depression consistent with acute pericarditis. His chest x-ray was interpreted as no acute cardiopulmonary disease. 

The patient's chest exam revealed a faint friction rub. Bedside cardiac ultrasound revealed a mild-to-moderate pericardial effusion. 

The patient's troponin came back at 0.29 and returned to undetectable levels on serial checks. A subsequent formal ECHO study revealed normal cardiac function including normal ejection fraction. 

The patient was admitted to the hospital overnight. His pain improved with oral ibuprofen. A repeat ECG the next day showed resolution of the original ST-elevations and the patient was discharged home with follow-up with his primary care provider. 

Acute Pericarditis

Normally 15-60 cc of physiological fluid between visceral and parietal layers of the pericardium

Inflammatory conditions increase the amount of fluid in this space --> can result in cardiac tamponade depending on the amount of additional fluid and rate at which it increases

Etiologies: viral, idiopathic, post-myocardial (Dresser's syndrome), neoplastic, infectious, uremic, radiation, connective tissue disorders (SLE, RA, Sjogren's syndrome, etc)  

Patient history

• sharp pain of prolonged duration (often days) 
• pleuritic component
• worse when supine
• improved when sitting forward
• prodrome of fever and malaise, not always present but common 

Clinical findings = pericardial friction rub (best heard over left lower sternal border) 

ECG findings

• Stage 1 - diffuse ST-elevations with concave-upwards contour, PR-depressions (most common in II, aVF, V4-6)
• Stage 2 - ST segments become isoelectric and T waves flatten
• Stage 3 - symmetric T wave inversion throughout ECG 
• Stage 4 - normalization 

**PEARL** 

Anything that irritates the outer epicardium of the myocardium will produce ST-elevations. This explains why only transmural infarcts involving the epicardium result in ST-elevation, and why ST-elevations indicate that your pericardiocentesis needle is making contact with the outer myocardium.

Management

• evaluate and treat underlying cause (e.g. dialysis for uremia)
• NSAIDs 

References: 

Colletti JE, Tabas JA, Emergency Medicine: A Focused Review of the Core Curriculum, 1st Ed, 2008, Chapter 2: Cardiovascular Disorders, pages 237-242

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