Why it matters
Young adults with chest pain trigger an MI reflex, but the winner in this age group is often acute pericarditis. You’ll avoid unnecessary cath lab calls (and dangerous misses) by recognizing the pericarditis pattern quickly—and by knowing the red flags that mandate admission.
1) The 30-second story you should hear
- Sharp, pleuritic, positional chest pain (worse supine, better sitting forward)
- Recent viral prodrome (fever, myalgias, URI or GI illness)
- Possible pericardial friction rub on exam
- Low–normal vitals, unless there’s large effusion/tamponade
2) Quick differential (don’t anchor)
- Pericarditis / myopericarditis
- STEMI/NSTEMI (rare at 20, but not impossible—cocaine, anomalous coronaries, hypercoagulable states)
- PE, pneumothorax, pneumonia/pleurisy, costochondritis
- GERD/esophageal spasm, anxiety
Use the pattern + ECG to narrow, and POCUS to look for effusion.
3) ECG: pattern recognition (the rookie’s superpower)
Pericarditis clues
- Diffuse, concave ST elevation in many leads (not a single coronary territory)
- PR depression in multiple leads; PR elevation in aVR/V1
- No reciprocal ST depression (except aVR/V1)
- Spodick sign: down-sloping TP segment (often inferior/lateral leads)
- ST/T ratio in V6 > 0.25 favors pericarditis over early repolarization
- Evolution over days: ST↑/PR↓ → normalization → T-wave inversion → resolution
STEMI contrast
- Regional (territorial) ST changes, often with reciprocal depression and evolving Q waves/hyperacute T waves.
4) Bedside exam & POCUS
- Friction rub: scratchy, triphasic; louder leaning forward (don’t chase it—often transient).
- POCUS: look for pericardial effusion and tamponade signs (RV diastolic collapse, plethoric IVC, swinging heart).
- Red flags: hypotension, JVD, muffled heart sounds (Beck’s triad), tachycardia out of proportion.
5) Labs & tests you actually need
- ECG (serial if pain persists)
- Troponin (mild ↑ suggests myopericarditis; treat more cautiously)
- CRP/ESR (supportive; helpful to follow)
- BMP (electrolytes, renal function before NSAIDs/colchicine)
- CXR (cardiomegaly if large effusion; alternate diagnoses)
- Echo (formal or POCUS) for all suspected pericarditis if available—assess effusion/tamponade
- Targeted tests if atypical: HIV, TB risk, autoimmune panel, thyroid, etc. (not routine in classic viral cases)
6) Red flags — admit these 🚨
- Temp >38 °C, subacute onset (>1 week), or immunosuppression
- Large effusion (>20 mm) or any tamponade physiology
- Myopericarditis (↑troponin with LV dysfunction or significant chest pain)
- Anticoagulation or trauma (hemopericardium risk)
- Poor response to NSAIDs within 1 week
- Elevated troponin with dynamic ECG changes you can’t confidently attribute to pericarditis
7) ED management (uncomplicated, likely viral pericarditis)
Analgesia & anti-inflammation
- Ibuprofen 600–800 mg PO q8h (or Aspirin 750–1,000 mg PO q8h) + PPI
- Colchicine improves symptom control & reduces recurrence:
- ≥70 kg: 0.5–0.6 mg PO BID for 3 months
- <70 kg: 0.5–0.6 mg PO daily for 3 months
- Avoid steroids as first line (higher recurrence). Consider only if NSAIDs/colchicine contraindicated or specific etiologies (autoimmune) after specialist input.
If myopericarditis suspected
- Avoid strenuous exercise; be cautious with high-dose NSAIDs if significant myocardial involvement.
- Cardiology input; consider brief observation/admission depending on symptoms, troponin trend, echo.
Tamponade
- Emergent pericardiocentesis (if crashing) and cardiology/CT surgery involvement.
8) Disposition & discharge instructions
Safe discharge (all true):
- Hemodynamically stable, no red flags, pain controlled, no/trace effusion on POCUS/echo, reliable follow-up.
- Prescription: NSAID + PPI + colchicine regimen as above.
- Activity: No sports/exertion until symptom-free and ECG/CRP normalize (usually weeks).
- Return immediately for: syncope, dyspnea at rest, worsening pain, fever, lightheadedness, or new swelling.
- Follow-up: cardiology/IM in 48–72 h to reassess symptoms, ECG, and arrange formal echo if not done.
Admit/observe if any red flags, diagnostic uncertainty, moderate/large effusion, persistent tachycardia, hypotension, or elevated troponin with concerning features.
Rookie pearls
- Diffusely upsloping ST + PR depression = think pericarditis.
- Don’t forget to check aVR/V1 for PR elevation.
- POCUS early—a small effusion supports the diagnosis; a big one changes the plan.
- Colchicine halves recurrences; write it every time unless contraindicated.
- If the ECG is screaming “territory,” don’t force it into pericarditis—call for help and manage as ACS.
- Exercise restriction is not a throw-away line—say it clearly to the patient.
Common pitfalls
- Calling early repolarization “pericarditis” (use ST/T ratio in V6 and the clinical story).
- Forgetting a pregnancy test and NSAID counseling in women of child-bearing potential.
- Treating myopericarditis like simple pericarditis—watch the troponin/echo.
- Starting steroids first-line—expect more recurrences.
- Discharging a patient with large effusion or resting tachycardia without observation.
Leave a Reply