Pericarditis differential diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]
Differentiating Pericarditis from other Conditions
Several conditions, including life threatening conditions such as myocardial infarction, aortic dissection and pulmonary embolism produce signs and symptoms that are similar to those produced by pericarditis.
- Pain along the trapezius ridge(s), is very characteristic of pericarditis. The pain of myocardial infarction tends to involve the anterior precordium with radiation to the left arm.
- Unlike cardiac ischemia, the pain of pericarditis often lasts longer, is sharper and unresponsive to vasodilator therapy.
- The EKG of pericarditis shows PR segment depression while the EKG of myocardial infarction does not.
- The EKG of pericarditis shows ST elevation that does not necessarily follow the anatomic distribution of a single coronary artery.
Clinical presentation
Substernal or left precordial pleuritic Chest pain with radiation to the trapezius ridge (the bottom portion of scapula on the back), which is relieved by sitting up and bending forward and worsened by lying down (recumbent or supine position) or inspiration (taking a breath in), is the characteristic pain of pericarditis.[1] The pain, may resemble the pain of angina pectoris or heart attack but differs in that pain changes by body positions, as opposed to heart attack pain that is pressure-like, and constant with radiation to the left arm and/or the jaw. Other symptoms of pericarditis may include dry cough, fever, fatigue, and anxiety. Due to similarity to myocardial infarction (heart attack) pain, pericarditis can be misdiagnosed as an acute myocardial infarction (a heart attack) solely based on the clinical data and so extreme suspicion on the part of the diagnostician is required. Ironically an acute myocardial infarction (heart attack) can also cause pericarditis, but often the presenting symptoms vary enough to warrant a diagnosis. The following table organises the clinical presentation of pericarditis:[1]
| Characteristic/Parameter | Pericarditis | Myocardial infarction |
|---|---|---|
| Pain description | Sharp, pleuritic, retro-sternal (under the sternum) or left precordial (left chest) pain | Crushing, pressure-like, heavy pain. Described as "elephant on the chest." |
| Radiation | Pain radiates to the trapezius ridge (to the lowest portion of the scapula on the back) or no radiation. | Pain radiates to the jaw, or the left or arm, or does not radiate. |
| Exertion | Does not change the pain | Can increase the pain |
| Position | Pain is worse supine or upon inspiration (breathing in) | Not positional |
| Onset/duration | Sudden pain, that lasts for hours or sometimes days before a patient comes to the ER | Sudden or chronically worsening pain that can come and go in paroxysms or it can last for hours before the patient decides to come to the ER |