Case Study: Substernal Chest Pressure in a Young Man

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Prompt diagnosis after chest pain in young patients is vital for optimal outcomes.
Prompt diagnosis after chest pain in young patients is vital for optimal outcomes.

Case:

A 23-year-old man with no significant medical history presented to a local hospital emergency department complaining of intermittent chest pain for 1 day. The patient reports pressure-like substernal pain of a duration of 30 to 45 minutes, radiating to both arms.

He stated his chest pain is somewhat relieved by sitting upright. Coughing or sneezing did not exacerbate his chest pain. He denied shortness of breath. He stated he is recovering from a lingering cold and has been sweating more than usual. Social history was significant for smoking 1 pack of cigarettes per day; the patient denied use of illicit drugs.

The patient appeared well nourished and mildly distressed. Physical examination revealed tachycardia at 105 bpm, blood pressure 125/74 mm Hg, and bilateral tonsillar exudates with erythema and edema of the posterior tonsils. Cardiac examination revealed normal S1 and S2, no murmurs, gallops, or rubs; examination was negative for jugular venous distention. Lungs were clear on auscultation bilaterally.

 

Laboratory findings revealed a markedly elevated troponin of 3 mg/dL, a white blood cell count of 15,000 µ/L, and an erythrocyte sedimentation rate of 28 mm/H. Urine toxicology was negative.

A 12-lead electrocardiogram showing ST-segment elevation with PR depression was obtained in the emergency department.

What is the most likely diagnosis? 

  • Gastroesophageal reflux disease
  • Myopericarditis
  • Cocaine-induced angina
  • Angina

Discussion:

The electrocardiogram above shows evidence of PR depression in leads V1-V5 with diffuse ST elevation best in leads II, and V2-V5. Given the clinical scenario the most likely diagnosis is myopericarditis.

Clinical features that are highly suggestive of pericarditis include 2 of the following: sharp pleuritic chest pain, pericardial friction rub on examination, diffuse ST-segment elevation without the reciprocal changes expected in a myocardial infarction, PR-segment depression, and the presence of a pericardial effusion on echocardiogram.

In this setting, serum elevation of cardiac biomarkers without wall motion abnormalities or reduced left ventricular systolic function on echocardiogram suggests primarily pericardial involvement with minor myocardial involvement. New segmental or global wall motion abnormalities would suggest more significant myocardial involvement and should be treated as myocarditis. When ventricular function is preserved, treatment is usually the same as for pericarditis.

The mainstay of therapy for pericarditis is nonsteroidal anti-inflammatory drugs (NSAIDS). However, NSAIDS have been shown to increase mortality in the setting of myocardial inflammation/injury.1 Therefore, the consensus is to use the lowest dose of NSAIDS that provides symptom relief.

Most recently, there has been a growing body of evidence regarding the benefits of colchicine in treating acute and recurrent pericarditis. Cardiac magnetic resonance imaging data suggest this may also be beneficial in the treatment of patients with comorbid myocarditis; however, more research is needed.2


References

  1. Rezkalla S, Khatib G, Khatib R. Coxsackievirus B3 murine myocarditis: deleterious effects of nonsteroidal anti-inflammatory agents. J Lab Clin Med. 1986;107(4):393-395.
  2. Morgenstern D, Lisko J, Boniface NC, Mikolich BM, Mikolich JR. Myocarditis and colchicine: a new perspective from cardiac MRI. J Cardiovasc Magn Reson. 2016;18(1):O100. doi: 10.1186/1532-429X-18-S1-O100
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