Case 2: Chest Pain

Case 2: Chest Pain

History
A 34-year-old male accountant comes to the emergency department with acute chest pain.
There is a previous history of occasional stabbing chest pain for 2 years. The current pain
had come on 4 h earlier at 8 pm and has been persistent since then. It is central in position,
with some radiation to both sides of the chest. It is not associated with shortness of breath or
palpitations. The pain is relieved by sitting up and leaning forward. Two paracetamol tablets
taken earlier at 9 pm did not make any difference to the pain.
The previous chest pain had been occasional, lasting a second or two at a time and with no
particular precipitating factors. It has usually been on the left side of the chest, although the
position had varied.
Two weeks previously he had an upper respiratory tract infection that lasted 4 days. This con-
sisted of a sore throat, blocked nose, sneezing and a cough. His wife and two children were
ill at the same time with similar symptoms but have been well since then. He has a history of
migraine. In the family history his father had a myocardial infarction at the age of 51 years
and was found to have a marginally high cholesterol level. His mother and two sisters, aged
36 and 38 years, are well. After his father’s infarct the accountant had his lipids measured;
cholesterol was 5.1 mmol/L (desirable range, 5.5 mmol/L). He is a non-smoker who drinks 15
units of alcohol per week.

Examination
His pulse rate is 75/min, blood pressure 124/78 mmHg. His temperature is 37.8°C. There is
nothing abnormal to find in the cardiovascular and respiratory systems.

INVESTIGATIONS
• A chest X-ray is normal. The haemoglobin and white cell count are normal. ESR 46.
The troponin level is slightly raised. Other biochemical tests are normal.
• The electrocardiogram (ECG) is shown in Figure 2.1.

Question
I II III • What is the diagnosis?

AVR AVL AVF

V1 V2 V3

V4 V5 V6
Figure 2.1 Electrocardiogram.

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 100 Cases in Clinical Medicine

Answer 2
The previous chest pains lasting a second or two are unlikely to be of any real significance.
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. Chest pain due to pericarditis is usually sharp and pleuritic, and exacerbated
by inspiration or coughing. 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 pericarditis and unlike the upward convexity found in the ST elevation
after myocardial infarction. ST changes are typically present in most leads in acute pericardi-
tis, unlike the changes in myocardial infarction which are limited to anatomical groupings of
leads that correspond to the area of the infarct.
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. Pericardial rubs have a scratchy quality that is best heard
with the diaphragm of the stethoscope. Pericarditis often involves some adjacent myocardial
inflammation, and this could explain the rise in troponin levels. As pericarditis is an inflam-
matory disease, the white cell count, ESR and serum CRP are often raised. Echocardiography
often shows a small pericardial effusion, with tamponade being rare.
Pericarditis may occur as a complication of a myocardial infarction, but this tends to occur
a day or more later—inflammation either 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, tuberculosis, uraemia 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 muscu-
loskeletal pain, are not suggested by the history and investigations.
A subsequent rise in antibody titres against Coxsackie virus suggested a viral pericarditis.
Symptoms and ECG changes resolved in 4–5 days. An echocardiogram showed a small peri-
cardial efflusion and good left ventricular muscle function. The symptoms settled with rest
and non-steroidal anti-inflammatory drugs.

KEY POINTS

• ST segment elevation that 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 assessed from troponin measurements.