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Asian Journal of Healthy and Science

p-ISSN: 2980-4302

e-ISSN: 2980-4310

Vol. 2 No. 12 December 2023

Pericarditis is a common disorder that might present in various settings, including

primary-care and emergency department. However, the clinical features in some

cases did not match with the written theory, which could lead to a misdiagnosis. We

reported a 34-year-old female presented to the emergency room with progressive

tightness chest pain in the past 3 days, that got worse with a change in position and

penetrated to the back. Based on clinical chest pain with history of stable coronary

without any remainder symptoms. Acute pericarditis does not always show typical

clinical findings. Therefore, clinician must always aware with other differential

diagnosis of chest pain and ECG variation of acute pericarditis even though the

patient has a history of coronary artery disease.

hyperechoic pericardium, colchicine

INTRODUCTION

Acute pericarditis is still a diagnosis that is missed when a person complains of

chest pain. Chest pain due to pericarditis is about 5% of the total chest pain that often

arising from innervation by branches of the sympathetic trunk in the visceral

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pericardial layer following the distribution of the heart. Typical chest pain that is

often complained of is chest pain that pierces the retrosternal area, worsens during

inspiration, lying down, standing or sitting. Distinguishing chest pain due to acute

pericarditis and ischemic heart disease is still very difficult if symptoms are atypical

(Ismail, 2020).

The normal ECG in this patient is in stark contrast to the early-phase ECG seen

in acute pericarditis in general, PR depression in inferior leads (II,III, aVF) or

precordial leads V2-V6 or ST segment elevation which must also be distinguished

from myocardial infarction (Imazio et al., 2015). In this report, the patient with acute

A 34-year-old female being hospitalized to emergency room with progressive

tightness chest pain for 3 days ago. The typical chest pain was radiating to the neck

and left arm, got worse with a change in position and penetrated to the back, lasting

5-10 minutes. Chest pain does not improve when the patient rests, accompanied by

nausea. She felt short of breath when she was doing strenuous activities or walking

long distances. She had been diagnosed with stable coronary artery disease (CAD)

seven month ago because she felt radiating chest pain and got worse when activity

and improve when resting, finding of the slight ST depression on lead V1-V4 on

Electrocardiograph (ECG). She had received the medication for coronary artery

disease due to previous history; isosorbide dinitrate 5 mg if the complaint of chest

pain appears, clopidogrel 75 mg once daily, aspirin 80 mg once daily, spironolactone

within the normal limit. We could not check the CKMB, C-reactive protein and

troponin marker because limited laboratory equipment in remote islands hospital.

Based on clinical findings with history of stable coronary artery disease, we suspect

that the plaque has ruptured, the patient diagnosed with Non ST Elevation-Acute

Coronary Syndrome (NSTE-ACS). Isosorbide dinitrate and dual antiplatelet

(clopidogrel 300 mg and aspilet 320 mg) but didn’t show a significant progress. The

next day while being treated at the hospital, we did the echocardiography

examination. The Parasternal Long-Axis (PLAX) Echocardiogram view showed a

thickened pericardium in the lateral left ventricle accompanied by hyperechoic

(Figure 1a) and confirmed from the parasternal short-axis (PSAX) view, a thickened

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treatment. After hospital discharge, the patient was continued oral medication for 3

months. Follow-up evaluation showed normal sinus rhythm and reduction of

thickening pericardial layers on TTE without any existing symptoms.

.

Figure 1. Transthoracic echocardiography evaluation results:a) from Parasternal

Long-Axis (PLAX) Echocardiogram view showed a thickened pericardium in the

lateral left ventricle accompanied by hyperechoic;b) the parasternal short-axis

(PSAX) view showed a thickened and hyperechoic pericardium appears in the

RESULTS AND DISCUSSION

There had not been any gold standard criteria established to diagnose acute

pericarditis. Patients with pericarditis are currently evaluated using physical

(new or worsening).

In this case, the patients met three criteria, which were pericardial chest pain,

pericardial rub on auscultation and thickening of pericardial layers. We have been

mistaken by diagnosing this patient with NSTE-ACS because of the symptoms and

non-specific finding from the ECG evaluation. Retrosternal and sharp pain is present

in 95% of cases which are similar with other disorders. Radiation pain of pericarditis

could be indistinguishable to other disorders, and specific such as pleuritic,

influenced by swallowing movements and changes in posture, usually relieved by a

change in position to relieve pressure on the parietal pericardium such as leaning

forward or sitting in an upright position (not relieved by nitrates). These

other tools, even though in this patient the complaints of chest pain that appear are

not specific (Regmi & Siccardi, 2019).

Despite being an important tool, the picture is not pathognomonic and varies

in almost 40% of those diagnosed with acute pericarditis,8 including in this patient,

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the onset of chest pain was 3 days and the ECG was normal. These features do not

match the pathognomonic ECG changes. ECG changes only occurred 7 months after

the diagnosis of acute pericarditis by echocardiography. Findings slight ST

depression on lead V1-V4 on ECG treated as coronary artery disease, accompanied

by patients who did not complied with routine check-ups at risk of causing

misdiagnosis. In the early phase acute pericarditis with onset hours to days, PR

segment depression is seen with ST segment elevation. The second phase of the ECG

began to normalize with a general onset in the first week, early transitional J points

were still found at baseline before the T wave began to flatten. The third phase of the

effects (tamponade, restriction), are all provided by the TTE (Imazio et al., 2013)

(Bhardwaj et al., 2013). In 60% of pericarditis cases, pericardial effusion was found,

either new appearing or getting worse, mostly mild. In this patient not found the

pericardial effusion but there was the thickening and hyperechogenicity of pericardial

layers. Regrettably, TTE may have a disadvantages, including inadequate acoustic

window brought on by obesity or chronic obstructive pulmonary disease (COPD),

2013). Drug of choice for pericarditis should be depends on the patient’s history, co-

morbidities of the patients, and physician preference (Seidenberg & Haynes, 2006).

Colchicine could be given as combination therapy, may require supplementary

narcotic analgesics. Aspirin 80 mg once daily for 2 weeks and Colchicine 0,5 mg once

daily for 3 months were given to this patient and showed the good evaluation from

symptoms, ECG and TTE.

Each drug's discontinuation results in potential recurrences. Tapering off

should not be done unless the CRP is normal and the symptoms are absent (Pelliccia

et al., 2006). Prognosis is generally benign, we could assess from predictor of poor

prognostic outcome, that is divided into mayor and minor criteria. Mayor criteria are

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