Diagnosis: History, Physical Examination and ECG

(1)

Cardiology Department, Maria Vittoria Hospital and Department of Public Health and Pediatrics University of Torino, Torino, Italy

3.1 History

A number of different features may be helpful in the first diagnostic evaluation to address specific pericardial syndromes and potential aetiologies to be further investigated (Table 3.1).

Table 3.1

Features to be considered in the history of a patient with a suspected or known pericardial and myopericardial disease

	Feature
Past medical history	Previous irradiation
	Renal insufficiency with or without dialysis
	Previous infectious diseases (e.g. tuberculosis)
	Previous cardiac surgery
Recent history	Antecedent respiratory or gastrointestinal infection
	Fever (if >38 °C suggest a non-viral aetiology)
	Recent myocardial infarction
Known diseases	Systemic inflammatory diseases
	Metabolic diseases (e.g. hypothyroidism, renal insufficiency)
	Cancer (especially lung and breast cancer, lymphoma, leukaemias)^a
Drugs	Current or recent exposure to drugs that may cause a pericardial syndrome (see Chap. 2)
	Lupus-like syndrome (procainamide, hydralazine, methyldopa, isoniazid, phenytoin)
	Hypersensitivity pericarditis with eosinophilia (e.g. penicillins)
	Other (rare), e.g. antineoplastic drugs (often associated with a cardiomyopathy, may cause a pericardiopathy), doxorubicin (Adriamycin) and daunorubicin cytosine arabinoside, 5-fluorouracil, cyclophosphamide

^aAdditional neoplasms include melanoma and cancers of contiguous anatomical structures (e.g. oesophagus)

Symptoms of an inflammatory pericardial or myopericardial syndrome usually include chest pain, generally sharp, sudden in onset, retrosternal, pleuritic with inspiratory exacerbation (Fig. 3.1) as well as positional change: increased by lying down and attenuated during sitting and leaning forward. Pericardial pain is an example of referred pain. The cardiac general visceral sensory pain fibres follow the sympathetics back to the spinal cord. To simplify, there is a convergence of afferent signals to the same spinal cord segments from both the heart/pericardium and dermatomes of the thoracic wall and upper limb. The central nervous system does not clearly discern whether the pain is coming from the body wall or from the heart or pericardium, but it perceives the pain as coming from somewhere on the body wall, i.e. substernal pain, left arm/hand pain and jaw pain. On this basis, pericardial pain may simulate ischaemic chest pain (Fig. 3.2) [1–5].

Fig. 3.1

“Pericarditic” chest pain has pleuritic features and it is usually referred as retrosternal (Reproduced from Wikipedia, Author Ian Furst)

Fig. 3.2

“Pericarditic chest pain” as referred pain that may simulate “ischaemic chest pain” (Reproduced from OpenStax College, Autonomic Reflexes and Homeostasis http://cnx.org/content/m46579/1.2/)

Additional symptoms may include dyspnoea that may be caused by the exacerbation of pain with inspiration or concomitant effect of pericardial and/or pleural effusion. Non-specific symptoms include malaise, fever and cough. Fever is generally low-degree and fever >38 °C should raise the suspicion of a bacterial aetiology [1–5]. A list of potential symptoms is reported in Table 3.2.

Table 3.2

Common symptoms in pericardial and myopericardial diseases

Symptom	Pathophysiology
Chest pain (>90 % of cases)	“Pleuritic” with exacerbation with inspiration, lying down and deglutition due to increased attrition between inflamed pericardial layers
Dyspnoea	Exacerbation of pain with inspiration or concomitant effect of pericardial and/or pleural effusion and/or concomitant pleuropulmonary disease
Palpitations	Concomitant arrhythmias (e.g. supraventricular or ventricular premature beats, atrial fibrillation or flutter as most common; usually because of concomitant myocardial involvement)
Asthenia	May be related to the concomitant inflammation/infection or related to constrictive physiology developing during the pericardial disease (usually transient but may progress). May be related to cardiac tamponade
Myalgias	Usually related to the concomitant inflammation/infection and/or myopathic involvement of skeletal muscles by a potential myotropic agent
Symptoms related to compression of anatomic structures by a large effusion	Dysphagia, nausea, abdominal fullness, dyspnoea, orthopnoea
Symptoms of right heart failure	Constriction physiology

3.2 Physical Examination

Physical findings are variable in pericardial and myopericardial diseases.

Pericardial Rubs

A patient with acute or recurrent pericarditis and myopericarditis may have a normal physical examination. In about one third of cases, a pericardial rub may be heard. A pericardial rub is supposed to be generated by increased attrition of inflamed pericardial layers. It has typically a to-and-fro character, typically with up to three components, one systolic and two diastolic (early rapid ventricular filling and atrial systole), corresponding to major changes in the size of cardiac chambers (Fig. 3.3) [1].

Fig. 3.3

A pericardial rub may have up to three components: one systolic and two diastolic (early rapid ventricular filling and atrial systole), corresponding to major changes in the size of cardiac chambers

It resembles the sound of squeaky leather and often is described as grating, scratching or rasping. It is best heard with the patient sitting and leaning forward or in the genu-pectoral position (Fig. 3.4) since these positions enhance pericardial attrition (Fig. 3.5). The pericardial rub is a diagnostic criterion for the diagnosis of pericarditis [4–6].

Fig. 3.4

Two positions that may enhance the chance to detect pericardial rubs: (a) patient is sitting and leaning forward; (b) genu-pectoral position with the patient lying on his/her elbows and knees

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