Differentials
Pulmonary embolism (PE)
SIGNS / SYMPTOMS
Chest pain can be anterior, posterior, or lateral in location. It is in phase with respiration (no chest pain when the patient ceases breathing) and is not positional in nature.
Pericardial friction rub is rarely present.
A pleural friction rub can be detected in 3% of patients.[12][28][48]
If a patient has concomitant pericarditis and PE, a risk for tamponade exists when using anticoagulation due to bleeding in the pericardial space.[49] Monitoring for worsening effusion is recommended, with consideration of risk/benefit for those who are anticoagulated.
INVESTIGATIONS
Computed tomographic pulmonary angiography will show direct visualization of thrombus in a pulmonary artery.
Elevation of D-dimer (this may also be raised in pericarditis).[50]
ECG may show evidence of right ventricular dysfunction; however, ECG cannot definitively establish or eliminate PE as a diagnosis.[51][52][53]
Myocardial infarction or ischemia
SIGNS / SYMPTOMS
Chest pain is described as pressure-like, heavy, squeezing, and responsive to nitroglycerin. There is generally no variation with respiration or positional changes. Duration of pain is minutes to hours, rather than hours to days. Pericardial friction rub is generally absent (unless there is associated pericarditis).[12][28][48]
INVESTIGATIONS
ECG may show convex ST elevations in the distribution of coronary arteries; Q-waves may be present; PR segment depression is rare; inverted T-waves when ST segments are still elevated. Significant elevation of serum troponin and cardiac enzymes present if myocardial damage.
Coronary angiogram (invasive or CT) shows presence of thrombus with occlusion of the artery.
Pneumonia
SIGNS / SYMPTOMS
Associated with cough and fever. Note that the presence of pneumonia may also be related to the presence of concomitant pericarditis.
INVESTIGATIONS
Chest x-ray may show evidence of infiltrates.
The absence of concomitant ECG findings supporting pericarditis excludes significant pericardial involvement.
Pneumothorax
SIGNS / SYMPTOMS
Many of the signs and symptoms may overlap including sudden onset shortness of breath, tachycardia, and chest pain. Pericarditis pain may be more positional in nature.
Physical examination reveals absence of breath sounds, generally unilaterally.
Tracheal deviation may also be present.
INVESTIGATIONS
Chest x-ray confirms lung collapse.
Costochondritis
SIGNS / SYMPTOMS
There is reproducible tenderness with palpation of the costochondral junctions. The pain is exacerbated by moving the trunk.
Physical examination is otherwise normal.
INVESTIGATIONS
Normal ECG.
Echocardiography shows no evidence of pericardial involvement.
Myocarditis
SIGNS / SYMPTOMS
May be preceded by viral infection (or more rarely, bacterial or fungal infection).
Symptoms of myocarditis include chest pain (which may be pleuritic as a result of concomitant pericarditis), palpitations, fatigue, or signs of heart failure (e.g., peripheral edema, increasing dyspnea, and weight gain).
INVESTIGATIONS
The definitive test is endomyocardial biopsy, which shows lymphocyte infiltration and myocyte necrosis.
Cardiac enzymes or brain natriuretic protein may be raised.
Leukocytosis, eosinophilia, elevated erythrocyte sedimentation rate and C-reactive protein, and a rise in serum viral titres are common.
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