ANSWER 2
The previous chest pains lasting a second or two are unlikely to be of any real signifi-
cance. Cardiac pain, and virtually any other significant pain, lasts longer than this, and
stabbing momentary left-sided chest pains are quite common. The positive family history
increases the risk of ischaemic heart disease but there are no other risk factors evident
from the history and examination. The relief from sitting up and leaning forward is typical
of pain originating in the pericardium. The ECG shows elevation of the ST segment which
is concave upwards, typical of pericarditisand unlike the upward convexity found in the
ST elevation after myocardial infarction.
The story of an upper respiratory tract infection shortly before suggests that this may well
have a viral aetiology. The viruses commonly involved in pericarditis are Coxsackie B
viruses. The absence of a pericardial rub does not rule out pericarditis. Rubs often vary in
intensity and may not always be audible. If this diagnosis was suspected, it is often worth
listening again on a number of occasions for the rub. Pericarditis often involves some adja-
cent myocardial inflammation and this could explain the rise in creatine kinase.
Pericarditis may occur as a complication of a myocardial infarction but this tends to occur
a day or more later – either inflammation as a direct result of death of the underlying heart
muscle, or as a later immunological effect (Dressler’s syndrome). Pericarditis also occurs
as part of various connective tissue disorders, arteritides, tuberculosis and involvement
from other local infections or tumours. Myocardial infarction is not common at the age of
34 years but it certainly occurs. Other causes of chest pain, such as oesophageal pain or
musculoskeletal pain, are not suggested by the history and investigations.
Thrombolysis in the presence of pericarditis carries a slight risk of bleeding into the peri-
cardial space, which could produce cardiac tamponade. This arises when a fluid (an effu-
sion, blood or pus) in the pericardial space compresses the heart, producing a paradoxical
pulse with pressure dropping on inspiration, jugular venous pressure rising on inspiration
and a falling blood pressure. In this case, the evidence suggests pericarditis and thrombol-
ysis is not indicated. The ECG and enzymes should be followed, the patient re-examined
regularly for signs of tamponade, and analgesics given.
A subsequent rise in antibody titres against Coxsackie virus suggested a viral pericarditis.
Symptoms and ECG changes resolved in 4–5 days. An echocardiogram did not suggest any
pericardial fluid and showed good left ventricular muscle function. The symptoms settled
with rest and non-steroidal anti-inflammatory drugs.
- ST segment elevation which is concave upwards is characteristic of pericarditis.
- Viral pericarditis in young people is most often caused by Coxsackie viruses.
- Myocarditis may be associated with pericarditis, and muscle function should be assessed
on echocardiogram, and damage from creatine kinase and troponin measurements.