Positional pericardial pain

Specialty: Cardiovascular.

• chest pain of pericardial origin
• acute pericarditis pain that improves when leaning forward

Why it occurs

• Acute viral or idiopathic pericarditis
• Post-traumatic inflammatory pericardial effusion
• Acute myopericarditis
• Uremic pericarditis associated with acute or chronic renal failure
• Secondary pericardial neoplastic involvement (metastasis from lung or breast cancer)

Initial workup

12-lead electrocardiogram (search for diffuse ST segment elevation with superior concavity, PR segment depression, or generalized low voltage); Transthoracic echocardiogram to quantify the volume of the effusion, rule out signs of diastolic collapse of the right ventricle, and evaluate respiratory excursion of the interventricular septum; Quantitative serum determination of inflammatory markers (high-sensitive C-reactive protein, erythrocyte sedimentation rate) and cardiac enzymes (high-sensitivity troponin I) to assess associated myopericarditis.

Standard management

• Ibuprofen — non-steroidal anti-inflammatory indicated in acute idiopathic or viral pericarditis; 600 mg every 8 hours orally, fixedly prescribed for 10 to 14 days with subsequent gradual tapering and use of gastric mucosal protector
• Colchicine — anti-inflammatory indicated synergistically to enhance the therapeutic response and prevent recurrences; 0.5 mg daily or twice a day depending on body weight, for 3 months
• Acetylsalicylic acid — of choice in post-infarction pericardial pain; 500 to 1000 mg every 8 hours orally, discontinuing the use of other NSAIDs
• Prednisone (second-line systemic glucocorticoid indicated if NSAIDs and colchicine fail or if there is confirmed immune-mediated etiology; 0.2 to 0.5 mg/kg/day orally, with very slow gradual tapering to avoid relapses).