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Clinical

Non traumatic chest pain –


pericarditis
Andrew Mootham, Emergency Nurse Practitioner, Care UK.
E-mail for correspondence: andrew.mootham@hotmail.com

The pericardium as well as protecting and


Abstract restraining the heart it also determines cardiac
Pericarditis is an inflammation of the two layers of the thin, sac-like membrane filling by preventing over stretching of the
that surrounds the heart. This membrane is called the pericardium, so the term myocardium. (Asher, Klein and Loughton, 2004
pericarditis means inflammation of the pericardium. The causes of pericarditis p718).
are thought to be viral, fungal or bacterial in nature. Pericarditis may also Derrickson and Tortora (2009 p720) describe
present as a result of a myocardial infarction (MI). The presenting signs and pericarditis as falling into two categories; Acute
symptoms of pericarditis are described as a chest pain which may radiate to the Pericarditis (which begins suddenly and has no
arm and jaw, a pericardial friction rub (a scratching or creaking sound produced known cause (although may be linked to viral
by the layers of the pericardium rubbing over one another) on auscultation of infection) and chronic pericarditis (begins gradually
heart sounds. The diagnosis of straight forward pericarditis may be within the and symptoms are long lasting with an associated
scope of practice of the Emergency Care Practitioner (ECP). It would be possible build up of pericardial fluid).
for the ECP to reach a working diagnosis and even to initiate a treatment Evidence from the United States suggests that
regime, which would predominantly consist of providing analgesia to make the pericarditis is relatively rare, resulting in less than
patient more comfortable. one percent of hospital admissions. Pericarditis is
most common in men age twenty to fifty, although
Key words it does occur in woman as well. ( Jacob and Grimm
l Pericarditis l Pre-hospital setting l Analgesia l Emergency care 2013).
The causes of pericarditis are thought to be
Accepted for publication 25 March 2017 viral, fungal or bacterial in nature. Pericarditis may
also present as a result of a myocardial infarction
(MI). Davidson, Foulkes, Longmore, Mafi and

T his article will look at the pathophysiology,


signs and symptoms/presentation and
management of pericarditis.
It will examine the evidence relating to the
management of the condition and discuss the issues
Wilkinson (2010 p148) suggest that the cause may
be idiopathic (of unknown cause) or secondary
to; viruses (e.g. Coxsackie or influenza), bacterial
(e.g, pneumonia), fungal, post MI or caused by
medication or other complex complaints such as
surrounding the need for hospital admission versus uraemia in renal failure.
management within the community/primary care Both Davidson Et al (2010 p148) and Clancy,
setting. Graham, Illingworth, Robertson and Wyatt (2008
p80) identify “Dressler’s Syndrome” as a cause of
'Pericarditis is an inflammation of the two pericarditis.
layers of the thin, sac-like membrane that Unknown-2 (2013) identifies Dressler’s syndrome
surrounds the heart. This membrane is called as inflammation of the pericardial sack which
the pericardium, so the term pericarditis occurs after trauma to the pericardium for example
means inflammation of the pericardium.' post MI or after surgery.
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(Unknown 2013) The presenting signs and symptoms of


pericarditis are described by Derrickson and
Knudson (2011, p504) describes the pericardium Tortora (2009, p720) as a chest pain which may
as surrounding the cardiac muscle. Consisting of radiate to the arm and jaw, a pericardial friction rub
two layers of tissue, encapsulating part of the aorta (a scratching or creaking sound produced by the
and vena cava. layers of the pericardium rubbing over one another)

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Clinical

on auscultation of heart sounds. Clancy et al (2008 usually results from chest trauma, malignancy or
p80) suggest that auscultation of heart sounds may tuberculosis.
be unreliable due to the pericardial rub often being Hemopericardium – a collection of blood
intermittent, position and elusive. resulting from trauma to the heart or aorta
Clancy et al (2008, p80) further describe the (Dudzinski, Hung and Mak 2012 p81-82).
symptoms as a left sided or retrosternal chest pain Pericardial effusion may have significant
made worse by deep inspiration, changing position, homodynamic consequences as it leads to reduced
exercise and swallowing. filling of the heart and may produce a cardiac
Camm (1999 p727) suggests that the pain from tampanade. (Dudsinki et al 2012 p83).
pericarditis may be relieved by sitting forward and Shabatai (2004 p255) describes the
aggravated by lying prone or supine. heamodynamic effects of pericardial effusion as
Jacob and Grimm (2013) state that the patient being a spectrum from mild to life threatening,
may describe symptoms such as back/neck pain, supporting the statement of Dudsinki et al (2012
a dry cough and anxiety or fatigue as well as the p83) who also suggest a link between pericardial
classical chest pain. Knudson (2011 p504) identifies effusion and cardiac tampanade.
shortness of breath on exertion in addition to the Cardiac Tampanade is a collection of fluid within
symptoms identified by Camm (1999) and Jacob the pericardium which compresses the heart and
and Grimm (2013). prevents adequate cardiac filling thus reducing
Rahman and Liu (2011 p791) suggest that during cardiac output. This is a medical emergency (March
examination and assessment of patients presenting and schub 2013)
with query pericarditis will present symptoms Cardiac Tampanade can be suspected during a
such as a raised jugular vein pressure and pulsus clinical examination of the patient, Clancy Et al
paradoxus (a decrease in systolic blood pressure (2006 p340) describes “Becks Triad” which is a
during inspiration) in addition to the symptoms raised JVP, hypotension and muffled heart sounds.
identified above. Rahman et al (2011 p 791) also Imazio et al (2004 p 1042) have identified cardiac
suggests that the chest pain may be pleuritic in tampanade as being a poor prognostic indicator in
nature. patients suffering pericarditis.
Imazio, Parrini, Giuggia, Cecchi, Gaschimo, Constrictive Pericarditis is a long-term (chronic)
Demarie, Ghiso and Trinchero (2004 p1042) inflammation of the pericardium with thickening,
that pyrexia over 38°C, subacute onset, scarring, and muscle tightening/contracture (Zeive
immunodepression, trauma, oral anticoagulant 2012).
therapy, myopericarditis, severe pericardial Dato, Coluzzi. Al-Mohanni, Della Bona, Piro,
effusion, cardiac tampanade are all poor prognostic Natale, Luciani, Biasucci, and Crea (2008 p79)
indicators and could highlight more serious disease. describe constrictive pericarditis as a progressive
There is evidence to suggest that pericarditis can fibrotic change in the pericardium which constricts
lead to a number of ECG changes. Camm (1999 the myocardium impairing ventricular filling.
p728) suggests that in the first week the ECG will Zeive (2012) goes on to identify the difficulty
display ST segment elevation with a concave shape in reaching a diagnosis of constrictive pericarditis
to the ST segment. This change is seen within the as the signs and symptoms are similar to those of
anterior, inferior and lateral leads. cardiac tampanade and restrictive cardiomyopathy.
Rahman et al (2011 p792) identifies the ECG Dato, Coluzzi, AlMohanni, Della-Bona, Piro,
changes which may be evident in pericarditis as; Natale, Luciani, Biasucci and Crea (2008 p 79)
diffuse ST segment changes; ST elevation with a support the argument that it is difficult to reach
saddle/concave shape or ST segment depression. the correct diagnosis due to restrictive pericarditis
The ECG will often lack any reciprocal changes having a similar presentation to restrictive
between leads III and AVL. Changes will usually cardiomyopathy.
involve more than one cardiac territory. Their work highlights the importance of a correct
Pericarditis can become complicated. These diagnosis due to their being surgical intervention
complications are pericardial effusion which available for the long term management of
Dudzinski, Hung and Mak (2012 p81) describe as constrictive pericarditis.
an accumulation of fluid within the pericardial sac. The diagnosis of constrictive pericarditis can
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© 2017 MA Healthcare Ltd

The fluid can come from several aetiologies; therefore not be made purely using clinical skills
Hydopericardium – usually a non infective such as observation and auscultation of heart
collection of fluid occurring from similar situations sounds, patients who have a working diagnosis
as pleura effusion or ascites e.g. Heart or Liver of pericarditis should undergo imaging such as
Failure. plain xray and computed tomography/magnetic
Clyclopericardium – a collection of white fluid, resonance imaging scans to confirm the diagnosis.

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Clinical

Young, Glockner, Williamson, Morris, Araoz, Ibuprofen works by acting upon prostaglandins.
Julsrud, Schaff, Edwards, Oh and Breen (2012 The prostoglandins are involved in the
p1099) inflammatory response. Ibuprofen inhibits the
Once the working diagnosis of pericarditis synthesis of prostaglandin therefore reducing the
is reached the practitioner should formulate a inflammatory response. Ibuprofen does this by
treatment plan and consider the need for referral interfering with the action of an enzyme (cyclo-
for expert opinion. oxygenase) which catalyses the conversion of
Whilst considering the treatment/management arachidonic acid into prostaglandic . (Neupert,
of pericarditis it is important to differentiate Brugger, Euchenhofer, Brune and Geisslinger 1997
between uncomplicated pericarditis and constrictive p490). This is not specific to ibuprofen, all NSAIDs
pericarditis as there are differences in the way in work in this manner.
which the conditions are management. Wedro et al (2013) also support the short
Imazio et al (2004 p1042) suggest that pericarditis term use of narcotic analgesia such as codeine
should have “a brief and benign” course following and morphine for the management of the pain
treatment with oral non steroidal anti-inflammatory associated to pericarditis.
drugs (NSAIDS) Research undertake by Imazio et al (2004 p
Clancy et al (2006) support the use of NSAIDS 1043) suggests that low risk patients who do not
in the treatment of the symptoms (chest pain). present with any poor prognostic indicators (who
Additionally Clancy et al recommend bed rest and are therefore low risk) can be safely managed out
a referral to the cardiology team for review/advice of hospital. Their research considered the cases of
regards the treatment of the patient. This infers the 254 low risk patients and found that 87% of these
need for the patient to be admitted to hospital. patients were successfully managed at home the
Gianni and Solbiati (2012) identify the risk other 13% of patients suffered complications and
of recurrence of pericarditis and suggest that required hospital admission. It should be noted
up to 50% of patients may have a recurrence that patients within this trial received a clinical
of the condition. To avoid this recurrence examination, blood tests and appropriate imaging
they recommend the use of colchicine to treat study’s to support the diagnosis prior to the
pericarditis. The British Pharmaceutical Society formulation of a treatment plan and discharge from
(2012) identify colchicine as a drug normally used a day case hospital.
in the treatment of gout. They identify that it is A statement by Black and Thompson (2012)
safe for patients who cannot take NSAIDS and also does not support the care of chest pain patients at
those on anticoagulant therapy, there is also less home, suggesting all patients with non traumatic or
risk of fluid retention than NSAIDS. suspected cardiac chest pain need to be reviewed
The evidence regards analgesia for patients in hospital. Due to the differential diagnosis for
suffering with pericarditis points to the use of non traumatic chest pain having potentially life
NSAIDs there is no specific research or evidence to threatening consequences. Thompson and black
suggest the use of additional analgesia using opiate identify the differential diagnosis for chest pain
based medications such as codeine or morphine as being acute MI, acute coronary syndrome and
sulphate preparations. pulmonary embolism.
Brown, Cooke and Fisher (2013) advocates the The suggestion of avoiding hospital admission
use of morphine for the management of cardiac made by Imazio et al (2004) is based on research
chest pain, specifically recommending the use from an American study where the patients
the intravenous morphine to reduce the pain and attended a day hospital for their examinations
anxiety suffered by the patient and also reduce the and assessments and were discharged home on
pre-load on the heart. completion for treatment within the community;
Herlitz, Bang, Omerovic and Wireklint-Sundström the UK based evidence is suggestive that patients
(2011) support the statements made by Brown would need to be assessed by cardiology specialist
et al (2013) however their research is specific to doctors. This cardiology assessment will require a
acute coronary syndrome and does not support or visit to the emergency department as a minimum,
suggest the use of morphine as an analgesic option but in the experience of the author most patients
for pericarditis. will require admission to the medical assessment
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Wedro, Kulick and Sheil (2013) specifically unit or cardiology ward to allow for assessment
name ibuprofen as the NSAID of choice for the and treatment of their condition. Whilst the UK
management of pericarditis, highlighting the action based evidence does not specifically state that a
of the drug stating that ibuprofen reduces the patient would require admission to hospital the
inflammation of the pericardium and reduces fluid tests required to confirm the diagnosis infer that a
accumulated within the pericardium. hospital visit would be necessary.

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Clinical

Wedro et al (2013) identify that the patient would


require a chest x-ray, blood tests, an ECG and an Key points
echocardiogram.
The evidence presented by Wedro et al (2013) llPericarditis is an inflammation of the two layers of the thin, sac-like
positively supports referring the patient to hospital. membrane that surrounds the heart.
Where appropriate and the pathway is in place the
practitioner should be considering a referral direct llThis membrane is called the pericardium, so the term pericarditis means
to cardiology. inflammation of the pericardium. The causes of pericarditis are thought to be
There is evidence to suggest that pericarditis viral, fungal or bacterial in nature. Pericarditis may also present as a result of a
can be an acute or chronic in nature. The acute myocardial infarction (MI).
presentation has already been discussed at length
above. The chronic presentation of pericarditis llThe presenting signs and symptoms of pericarditis are described as a chest
is linked to the slow build up of fluid within the pain which may radiate to the arm and jaw, a pericardial friction rub (a
pericardial sac (Derrickson and Tortora (2009 scratching or creaking sound produced by the layers of the pericardium
p720). rubbing over one another) on auscultation of heart sounds.
This slow build up of fluid is a pericardial
effusion. llThe diagnosis of straight forward pericarditis may be within the scope of
The evidence presented above identifies the practice of the Emergency Care Practitioner (ECP).
fact that pericarditis can become complicated
by a pericardial effusion or by developing into llIt would be possible for the ECP to reach a working diagnosis and even to
constrictive pericarditis. initiate a treatment regime, which would predominantly consist of providing
The management of constrictive pericarditis is analgesia to make the patient more comfortable.
discussed by Lin, Zhou, Xiao, Wang and Wang
(2012) their statement identifies the need for
surgical intervention for the definitive treatment
of constrictive pericarditis. This work identifies The evidence presented makes it clear
the need for rapid identification of the presenting that the drug of choice is ibuprofen based
features of constrictive pericarditis, whilst the ECP upon the actions of NSAIDs being to reduce
would not be able to provide a definitive treatment inflammation by the inhibition of the synthesis of
they would be able to recognise it as a differential prostoglandins. However there is also evidence
diagnosis. to support the use of opiate based drugs such as
Pericardial effusion whilst it is not something codeine in addition to ibuprofen.
which can be managed by the ECP. The ECP has Considering constrictive pericarditis there are
the skills to be able to recognise it as a possible difficulties in reaching the correct diagnosis
differential diagnosis based on findings from a as the condition mimics other conditions e.g.
cardiac assessment. Salami, Adeoye, Adegboye and restrictive cardiomyopathy. Without detailed
Adebo (2012 p407) describe symptoms of Becks and comprehensive imaging it would be near
Triad with shortness of breath as the key features in impossible for the ECP working within the
the presentation of pericardial effusion. community to be able to reach the correct
Salami et al (2012 p408) also describe the diagnosis.
management of this condition as requiring a There is also evidence which suggests that
pericardial drain. the differentiation between pericarditis and MI
In the cases of both a pericardial effusion and can be difficult due to both conditions having
constricive pericarditis is it the role of the ECP to only subtle differences in presentation and also
consider these as a possible differential diagnosis the risk of pericardial effusion and or cardiac
in young patients presenting with chest pain of a tampanade as a result of pericarditis I believe
non traumatic nature and refer the patient to an the evidence shows that it would unsafe for
appropriate care centre. patients to be treated within the community and
not reviewed and monitored within a hospital
Conclusion environment.
The diagnosis of straight forward pericarditis may The evidence is clear that the ECP should refer
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© 2017 MA Healthcare Ltd

be within the scope of practice of the Emergency patients who they suspect to have pericarditis
Care Practitioner (ECP). It would be possible to an appropriate secondary care facility. In
for the ECP to reach a working diagnosis and line with local guidelines and agreements this
even to initiate a treatment regime, which would referral may be via acute medicine or direct to
predominantly consist of providing analgesia to cardiology. JPP
make the patient more comfortable.

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Clinical

GRIMM R and JACOB RA. 2013. Pericardial Disease. Online.


References Available from http://www.clevelandclinicmeded.com/
AL-MOHANNI G, BIASUCCI LM, COLUZZI G, CREA F, DATO I
medicalpubs/diseasemanagement/cardiology/pericardial-
, DELLA-BONA R, LUCIANI N, NATALE L and PIRO M. 2008.
disease/ [Accessed 7th March 2013]
A young man with intractable ascites and effort dyspnoea
without echocardiographic signs of pericardial thickening: The HERLITZ J, BANG A, OMEROVIC E and WIREKLINT-
importance of clinical investigation, CT scan and MRI in the SUNDSTRÖM B. 2011. Is pre-hospital treatment of chest pain
diagnosis of constrictive pericarditis. International Journal of optimal in acute coronary syndrome? The relief of both pain
Cardiology, 128 (2), p.79-81. and anxiety is needed. International Journal of Cardiology, 149
(2), p.147 - 151.
ARAOZ P, BREEN J, EDWARDS W, GLOCKNER J, JULSRUD P,
MORRIS M, OH J, SCHAFF H, WILLIAMSON E and YOUNG IMAZIO M, PARRINI I, GIUGGIA M, CECCHI E, GASCHIMO G,
P. 2012. MR imaging findings in 76 consecutive surgically DEMARIE D, GHISO A and TRINCHERO R. 2004. Day-hospital
proven cases of pericardial disease with CT and pathologic treatment of acute pericarditis: a management program
correlation.. The International Journal Of Cardiovascular for outpatient therapy.. Journal of the American College of
Imaging, 28 (5), p.1099. Cardiology ( JACC), 43 (6), p.1042-6.
ASHER C, KLEIN A, TROUGHTON R. 2004 Pericarditis. Lancet,
363 (9410), p.81-82. KNUDSON, J. 2011. Diseases of the Pericardium. Congenital
BLACK J and THOMPSON F. 2012. Clinical Directive 85 – High Heart Disease, 6 (5), p.504.
Risk Non Traumatic Chest Pain. South Central Ambulance LIN Y, ZHOU M, XIAO J, WANG B and WANG Z. 2012. Treating
Service NHS Trust: Winchester. (Shown at Appendix 1) constrictive pericarditis in a chinese single-center study: a
BROWN S, COOKE M and FISHER J. 2013. UK Ambulance five-year experience.. The Annals Of Thoracic Surgery [Ann
Services Clinical Practice Guidelines 2013. JRCALC(AACE): Thorac Surg], 94 (4), p.1235 - 1240.
Warwick LUI, D. and RAHMAN, A. 2011 Pericarditis Clinical features and
BRITISH PHARMACEUTICAL SOCIETY. 2012. British National management. Australian Family Physician, 40 (10), p.791 - 792.
Formulary (62). BPS: London. MARCH P and SCHUB T. 2013. Quick Lesson – Cardiac
CAMM, A.1999. Cardiovascular Disease. In: Kumar, P. and Clarke, Tampanade. Online. Available from http://ehis.ebscohost.com/
M. eds. 1999. Clinical Medicine. 4th ed. Edinburgh: WB eds/pdfviewer/pdfviewer?sid=20faa934-b334-402f-bdfd-6a0dfd
Saunders, p.727-728. 1f4360%40sessionmgr104andvid=23andhid=115 [Accessed 11th
March 2013].
CLANCY MJ, GRAHAM CA, ILLINGWORTH RN, ROBERTSON CE
and WYATT JP. 2008. The Oxford Handbook of Emergency NEUPERT W, BRUGGER R, EUCHENHOFER C, BRUNE K and
Medicine. Oxford University Press: Oxford. GEISSLINGER G. 1997. Effects of ibuprofen enantiomers
and its coenzyme A thioesters on human prostaglandin
DATO I, COLUZZI G, ALMOHANNI G, DELLA-BONA R, PIRO
endoperoxide synthases. British Journal of Pharmacology, 122
M, NATALE L, LUCIANI N, BIASUCCI LM and CREA F. 2008.
(0), p.487 - 492.
A young man with intractable ascites and effort dyspnoea
without echocardiographic signs of pericardial thickening: the SALAMI MA, ADEOYE PO, ADEGBOYE AO and ADEBO VO.
importance of clinical investigation, CT scan and MRI in the 2012. Presentation pattern and management of effusive-
diagnosis of constrictive pericarditis.. The International Journal constrictive pericarditis in Ibadan.. Cardiovascular Journal of
of Cardiology, 128 (2), p.79 - 81. Africa, 23 (4), p.206 - 2011.
DAVIDSON EH, FOULKES A, LONGMORE M, MAFI AR and SHABATAI, R. 2004. Pericardial Effusion: Heamodynamic
Spectrum. Heart (British Cardiac Society), 90 (3), p.255 - 256.
WILKINSON IB. 2010. The Oxford Handbook of Clinical
Medicine. Oxford University Press: Oxford UNKNOWN. 2013. Definition of Pericarditis. [online]. Available
from: http://medical-dictionary.thefreedictionary.com/
DERRICKSON BH and TORTORA GJ. 2009. Principles of
pericarditis [Accessed 7 March 2013].
Anatomy and Physiology (12th Ed). Wiley and Sons: Asia
UNKNOWN-2. 2013. Definition of Dresslers Syndrome. Online.
DUDZINSKI D, HUNG J and MAK J. 2012. Pericardial diseases.
Available from http://www.mayoclinic.com/health/dresslers-
Current Problems in Cardiology, 37 (3), p.75-118.
syndrome/DS00666 [Accessed 7th March 2013]
GIANNI F and SOLBIATI M. 2012. Colchicine is safe and effective
WEDRO B, KULICK DL and SHEIL WC 2013. Pericarditis. [online]
for secondary prevention of recurrent pericarditis.. Internal
Available at: http://www.medicinenet.com/pericarditis/page4.
and Emergency Medicine, Apr 7 (2), p.181 - 182. GIANNI, F.
htm [Accessed: 1 Apr 2013].
and SOLBIATI, M. (2012) Colchicine is safe and effective for
secondary prevention of recurrent pericarditis.. Internal and ZEIVE D. 2012. Constrictive Pericarditis. Online. Available from
Emergency Medicine, Apr 7 (2), p.181 - 182. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002093/
[Accessed 12th March 2013] © 2017 MA Healthcare Ltd

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