By Ahmed Adlan
2 November 2014
A seventy year old man presents to the emergency department following a severe episode of chest pain described as "like my angina only worse". Past medical history includes angina based on an abnormal coronary angiogram performed 18 years ago, rheumatoid arthritis and hypothyroidism. Medications include aspirin, statin, levothyroxine, methotrexate, hydroxychloroquine, folic acid and sublingual glyceryl-trinitrate.
Clinical examination was unremarkable. Blood pressure was 135/80 mm/Hg, heart rate 85 beats per minute, oxygen saturation was 98% on air whilst tympanic temperature was 37.5 degrees centigrade.
Admission ECG is shown in Figure 1.
Serial troponins were negative, repeat ECG showed no dynamic changes and he was managed as unstable angina. Plain chest radiograph was unremarkable. Routine blood tests showed a leucocytosis (white cell count 12 x 10^9/L) with increased neutrophil count. C-reactive protein was slightly elevated at 12 mg/L (normal < 10 mg/L).
Several hours later he developed a severe episode of chest pain not relieved by sublingual glyceryl-trinitrate. A repeat ECG was performed (Figure 2).
At this stage he was referred to a Cardiologist for consideration of primary percutaneous intervention for ST elevation myocardial infarction.
On further questioning he described a "sharp" chest pain that radiated to his neck, shoulders and back and improved with leaning backwards. He reported similar episodes over the last few months which he attributed to angina. Sublingual glyceryl-trinitrate would not consistently relieve the pain. Bedside echocardiography showed normal left ventricular systolic function with no regional wall motion abnormalities. A small pericardial effusion was seen causing no significant haemodynamic compromise. A diagnosis of pericarditis was made and the patient was commenced on non-steroidal anti-inflammatory therapy. He remained pain free and was discharged 24 hours later.
Learning points
Clinical history and examination
Pericarditis should always be considered in the differential diagnosis of acute chest pain especially in the presence of ST elevation. The chest pain is typically sharp and may radiate to the neck, shoulder or back and is relieved by leaning forward. It is recommended to check for a history of preceding viral illness or associated conditions including immunological (e.g. connective tissue disease, rheumatoid arthritis), malignancy or recent myocardial infarction (Dressler's syndrome). Clinical examination may often reveal a pericardial rub.
In the above case the description of the chest pain was key to making the diagnosis. The patient had attributed his chest pain to angina which was misleading to the admitting physician. On careful questioning it can be seen that the "angina pain" he described was more consistent with pericarditis.
ECG and echocardiography
In pericarditis ST elevation is usually saddle-shaped with widespread changes not fitting a particular coronary artery territory, and an absence of reciprocal ischaemic changes (e.g. ST depression, Figure 3). PR depression may be present and in aVR reciprocal ST depression and PR elevation is often seen (Figure 3). An elevated Troponin suggests involvement of the myocardium (myopericarditis). Echocardiography may reveal a pericardial effusion and should be performed in cases of suspected cardiac tamponade (Figure 4).
Rheumatoid arthritis pericarditis
Rheumatoid arthritis is an inflammatory condition predominantly affecting the synovial joints, and is associated with increased cardiovascular risk [1]. Pericarditis is the commonest cardiac manifestation in rheumatoid arthritis occurring in 30-50% of patients [2]. Pericarditis occurs more commonly in males and is usually associated with destructive and nodular disease. Treatment involves non-steroidal anti-inflammatory drugs, corticosteroids, and/or other immunosuppressive agents. Pericardiectomy may be considered in extreme cases. Rheumatoid arthritis with pericardial involvement carries a worse prognosis.
References
1. Van Doornum S, McColl G, Wicks IP. Accelerated atherosclerosis. An extraarticular feature of rheumatoid arthritis? Arthritis Rheum 2002; 46: 862-73.
2. Voskuyl A. The heart and cardiovascular manifestations in rheumatoid arthritis. Rheumatology 2006; 45 (4): iv4-iv7.
2 November 2014
A seventy year old man presents to the emergency department following a severe episode of chest pain described as "like my angina only worse". Past medical history includes angina based on an abnormal coronary angiogram performed 18 years ago, rheumatoid arthritis and hypothyroidism. Medications include aspirin, statin, levothyroxine, methotrexate, hydroxychloroquine, folic acid and sublingual glyceryl-trinitrate.
Clinical examination was unremarkable. Blood pressure was 135/80 mm/Hg, heart rate 85 beats per minute, oxygen saturation was 98% on air whilst tympanic temperature was 37.5 degrees centigrade.
Admission ECG is shown in Figure 1.
 |
| Figure 1. Admission ECG. (Open in another window) |
Serial troponins were negative, repeat ECG showed no dynamic changes and he was managed as unstable angina. Plain chest radiograph was unremarkable. Routine blood tests showed a leucocytosis (white cell count 12 x 10^9/L) with increased neutrophil count. C-reactive protein was slightly elevated at 12 mg/L (normal < 10 mg/L).
Several hours later he developed a severe episode of chest pain not relieved by sublingual glyceryl-trinitrate. A repeat ECG was performed (Figure 2).
 |
| Figure 2. Repeat ECG (Open in another window) |
At this stage he was referred to a Cardiologist for consideration of primary percutaneous intervention for ST elevation myocardial infarction.
On further questioning he described a "sharp" chest pain that radiated to his neck, shoulders and back and improved with leaning backwards. He reported similar episodes over the last few months which he attributed to angina. Sublingual glyceryl-trinitrate would not consistently relieve the pain. Bedside echocardiography showed normal left ventricular systolic function with no regional wall motion abnormalities. A small pericardial effusion was seen causing no significant haemodynamic compromise. A diagnosis of pericarditis was made and the patient was commenced on non-steroidal anti-inflammatory therapy. He remained pain free and was discharged 24 hours later.
Learning points
Clinical history and examination
Pericarditis should always be considered in the differential diagnosis of acute chest pain especially in the presence of ST elevation. The chest pain is typically sharp and may radiate to the neck, shoulder or back and is relieved by leaning forward. It is recommended to check for a history of preceding viral illness or associated conditions including immunological (e.g. connective tissue disease, rheumatoid arthritis), malignancy or recent myocardial infarction (Dressler's syndrome). Clinical examination may often reveal a pericardial rub.
In the above case the description of the chest pain was key to making the diagnosis. The patient had attributed his chest pain to angina which was misleading to the admitting physician. On careful questioning it can be seen that the "angina pain" he described was more consistent with pericarditis.
ECG and echocardiography
In pericarditis ST elevation is usually saddle-shaped with widespread changes not fitting a particular coronary artery territory, and an absence of reciprocal ischaemic changes (e.g. ST depression, Figure 3). PR depression may be present and in aVR reciprocal ST depression and PR elevation is often seen (Figure 3). An elevated Troponin suggests involvement of the myocardium (myopericarditis). Echocardiography may reveal a pericardial effusion and should be performed in cases of suspected cardiac tamponade (Figure 4).
 |
| Figure 3. ECG features of pericarditis (Open in another window) |
 |
| Figure 4. Echocardiogram showing massive pericardial effusion causing cardiac tamponade (Image courtesy of wikipedia) |
Rheumatoid arthritis pericarditis
Rheumatoid arthritis is an inflammatory condition predominantly affecting the synovial joints, and is associated with increased cardiovascular risk [1]. Pericarditis is the commonest cardiac manifestation in rheumatoid arthritis occurring in 30-50% of patients [2]. Pericarditis occurs more commonly in males and is usually associated with destructive and nodular disease. Treatment involves non-steroidal anti-inflammatory drugs, corticosteroids, and/or other immunosuppressive agents. Pericardiectomy may be considered in extreme cases. Rheumatoid arthritis with pericardial involvement carries a worse prognosis.
References
1. Van Doornum S, McColl G, Wicks IP. Accelerated atherosclerosis. An extraarticular feature of rheumatoid arthritis? Arthritis Rheum 2002; 46: 862-73.
2. Voskuyl A. The heart and cardiovascular manifestations in rheumatoid arthritis. Rheumatology 2006; 45 (4): iv4-iv7.
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