Cardiology Case Challenge: Worsening Chest Pain After a Respiratory Infection in a Man With Hypertension

Abhimanyu Beri, MD; Fadi Abu-Yasin, MD


March 24, 2022


This patient presented with retrosternal chest pain, which began while he was at rest and radiated to the right shoulder and neck. The pain worsened on deep inspiration and while lying down, but it improved when he bent forward. In addition, a friction rub was detected on repeat examination. The initial ECG showed mild ST-segment elevation in the inferior and anterior leads that became much more pronounced over the following 12 hours, as well as PR-segment elevation in lead aVR. These findings prompted the diagnosis of acute pericarditis.

Acute pericarditis may occur as an isolated entity or as the result of systemic disease. The incidence is estimated to be about 5% of emergency department patients with chest pain but without myocardial infarction. Most cases are idiopathic; however, the clinician must also consider infectious, neoplastic, autoimmune, uremic, radiation-induced, postischemic, postvaccine, and traumatic etiologies. Important conditions that may cause chest pain similar to that of pericarditis include myocardial infarction, pulmonary embolism, aortic dissection, pleural effusion, and pneumomediastinum.[1,2,3]

The typical history for a patient with acute pericarditis consists of chest pain that is sudden in onset and pleuritic in nature. It is usually more intense when the patient is supine and improves when he or she sits upright and leans forward. The pain often radiates to the neck, upper arm, or shoulder as referred pain from the phrenic nerve's course over the pericardium.

The physical examination may reveal a high-pitched scratchy or squeaky friction rub that is best heard at the left sternal border at end expiration when the patient is leaning forward. Because pericardial friction rubs often vary in intensity from minute to minute, patients who have suspected pericarditis should have cardiac auscultation repeated multiple times. The friction rub is classically described as having three components, which correspond to atrial systole, ventricular systole, and rapid ventricular filling during early diastole; however, all phases may not be discernible in all patients. A pericardial friction rub can be distinguished from a pleural rub by the fact that it can be heard even when respirations are suspended.[1,2,3]


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.