Abstract and Introduction
Abstract
Aim To describe clinical characteristics, assessment and treatment of patients diagnosed in an emergency department (ED) with acute pericarditis.
Methods A medical record review of patients with an ED diagnosis of pericarditis conducted in an adult tertiary hospital over a 5-year period. Variables collected included pain characteristics, associated symptoms, physical examination findings, investigation results, ED treatment and disposition.
Results 179 presentations were included, with 73.9% men and a mean age of 38.8 years. The majority of patients described pleuritic chest pain worse with inspiration with half characterising the pain as sharp or stabbing, with others describing tightness, dullness or cramping. Radiation to the left shoulder occurred in 2.8% and change of pain with posture occurred in 46.4%. A pericardial rub was documented in 19 presentations. All patients had an ECG recorded with ST segment elevation present in 69.3% and PR segment depression in 49.2%. Nearly 90% of patients had troponin testing but only 6.4% of these were positive. Only 8.1% of cases were treated with colchicine. No patients required pericardiocentesis. Patients with high-risk factors were more likely to have previous pericarditis, dyspnoea, nausea, abnormal investigation results, treatment with colchicine and admission to hospital. However, 16.9% of patients without risk factors were admitted, and 46.9% of patients with at least one risk factor were discharged.
Conclusions Pericarditis may not follow the classical clinical description. Admission and discharge decisions appear to relate to individual clinical characteristics rather than known risk factors. Use of colchicine for treatment in ED is infrequent.
Introduction
Acute pericarditis is an important differential diagnosis in the emergency department (ED) assessment of acute chest pain. Review articles have summarised understanding of the clinical presentation and management of acute pericarditis although based on minimal original data. There are few studies of the investigation or management of these patients with the exception of limited studies reviewing echocardiography, troponin use and some specific treatment modalities. Few of these studies involved ED patients.
Recognition of the ECG findings in pericarditis is important in the assessment of acute chest pain and typical ECG changes are frequently described. The significance of these changes in assisting diagnosis in the ED has not been described previously. Small studies have found that troponin rises are relatively common in acute pericarditis but are not associated with an increased risk of complication.
Imazio et al describe a management programme for outpatient therapy of low risk acute pericarditis diagnosed in a day hospital setting, but do not describe the population presenting to an ED, or the management of higher risk cases. Acute pericarditis has traditionally been treated with non-steroidal anti-inflammatory drugs (NSAIDs), but recurrence rates have been estimated at up to 32%. The use of colchicine as a treatment for first and recurrent presentations of acute pericarditis has demonstrated a reduction in recurrence in both settings.
The broad aims of this study were to describe the clinical features, ECG manifestations, investigation, management and disposition of adult patients who received an ED diagnosis of acute pericarditis. Comparison of patient groups was undertaken based on previously defined risk factors.