Acute Pericarditis Differential Diagnoses

  • Author: Sean Spangler, MD; Chief Editor: Joseph L Fredi, MD   more...
 
Updated: Oct 10, 2011
 
 

Diagnostic Considerations

The classic feature of chest pain and dyspnea with pericarditis may be subtle and can be confused with other diagnoses, particularly in elderly individuals. Be careful not to confuse pericarditis with esophageal disorders, costochondritis, or other causes of noncardiac chest pain. Pericarditis may occur after renal transplantation, which may be related to uremia or infections (eg, cytomegalovirus [CMV]). Liver disease has been noted in asymptomatic constrictive pericarditis.

Given an overall lack of specificity of clinical features, diagnostic protocols to determine the etiology for pericarditis have been described. Following specific protocols, several investigators determined a specific etiology in 14-22% of patients. In one study, cardiac tamponade and an unfavorable clinical outcome, with persistence of fever, significant pericardial effusion, or general illness lasting longer than 1 week, was highly associated with finding a specific etiology. See an example under Workup.

Small asymptomatic pericardial effusions in patients with acquired immunodeficiency syndrome (AIDS) may not require diagnostic evaluation.[18] Large symptomatic pericardial effusions should be investigated, because two thirds of such effusions are potentially infections or neoplasms. Tuberculous pericarditis can also occur.[8]

Tension pneumothorax may mimic cardiac tamponade. Trauma ultrasonography has limited this misdiagnosis.

Elevated central venous pressure (CVP) may be absent in patients with pericarditis and preexisting hypovolemia.

Differentiating pericarditis from acute MI

Aside from clues elicited from the history and physical examination, pericarditis can be difficult to distinguish from myocardial infarction (MI) and repolarization in patients who present with chest pain and ST-segment elevation on electrocardiograms (ECGs). The potential misdiagnosis of pericarditis for acute MI has led to unfortunate complications when thrombolytic therapy has been given.

Some ECG findings that may be helpful include the following:

  • Repolarization does not progress through stages and is uncommonly associated with PR depression. Serial monitoring of ECGs in young patients with chest pain helps differentiate early repolarization from acute pericarditis.
  • An ST-segment–to–T-wave ratio of 0.25 or more in V6 can distinguish acute pericarditis from early repolarization.
  • The ST segment in acute MI is usually convex, bowing upward with reciprocal changes, as opposed to concave ST segments without reciprocal changes observed in acute pericarditis and repolarization.

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Sean Spangler, MD  Cardiologist, William Beaumont Army Medical Center

Sean Spangler, MD is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

George R Aronoff, MD  Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Christopher A Fly, MD  Assistant Professor, Department of Emergency Medicine, Medical College of Georgia

Christopher A Fly, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Philip J Gentlesk, MD  Director, Cardiac Electrophysiology, Section of Cardiovascular Disease, Brooke Army Medical Center

Philip J Gentlesk, MD is a member of the following medical societies: American College of Cardiology and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Anupama Gowda, MBBS, MD  Consulting Staff, Atlanta Nephrology Associates, PC

Disclosure: Nothing to disclose.

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

James W Lohr, MD  Professor, Department of Internal Medicine, Division of Nephrology, Fellowship Program Director, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, and Central Society for Clinical Research

Disclosure: Genzyme Honoraria Speaking and teaching

G Shawn Lynchard, MD  Consulting Cardiologist, Medical Director of Cardiac Care Unit, Congestive Heart Failure Clinic, and ECG and Stress Testing Clinic, Brooke Army Medical Center

G Shawn Lynchard, MD is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

Chike Magnus Nzerue, MD  Associate Dean for Clinical Affairs, Vice-Chairman of Internal Medicine, Meharry Medical College

Chike Magnus Nzerue, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Society of Nephrology, and National Kidney Foundation

Disclosure: Nothing to disclose.

David A Peak, MD  Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Verena T Valley, MD  Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital

Verena T Valley, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Steven J Compton, MD, FACC, FACP  Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

Chief Editor

Joseph L Fredi, MD  Assistant Professor of Medicine, Director of Acute MI Program, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center

Joseph L Fredi, MD is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

References

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This 12-lead electrocardiogram is representative of pericarditis.
Stage 1 electrocardiograph changes in a patient with acute pericarditis.
Stage 2 ECG changes in patient with acute pericarditis obtained 3 days into clinical course.
Stage 3 electrocardiograph changes of acute pericarditis obtained 18 days into the clinical course. The patient had resolution of symptoms.
Stage 4 electrocardiograph changes in the same patient as in the previous images, taken approximately 3 months after acute pericardial illness. The patient remained symptom free despite continued T-wave inversion.
Chest radiographs revealing markedly enlarged cardiac silhouette and normal-appearing lung parenchyma in prepericardiocentesis (A) and postpericardiocentesis (B). Courtesy of Zhi Zhou, MD.
Recording of aortic pressure showing pulsus paradoxus. During inspiration, systolic pressure declines 20 mm Hg. Courtesy of Zhi Zhou, MD.
This ultrasonogram demonstrates a normal subcostal 4-chamber view of the heart. The pericardium is brightly reflective (echogenic or white in appearance). LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
This is a modified subcostal ultrasonographic view of the heart in which a thick anechoic (dark or black) stripe is seen surrounding the heart (H). The stripe represents a large amount of fluid (F) in the pericardium, indicating tamponade.
A subcostal ultrasonographic view of the heart in a patient who sustained a stab wound to the chest. A hemopericardium (Hem) can be seen surrounding the heart (II).
The ultrasonogram demonstrates a subcostal view of the heart with a large fat pad (black arrows) present anteriorly.
 
 
 
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