Review Question - QID 213895

This patient is presenting with chest pain that is positional (as the physician is unable to lay the patient flat in the decubitus position) with an ECG demonstrating diffuse ST elevation with PR depression, which is suggestive of pericarditis. Pericarditis can present with a pericardial effusion (an echogenic rim fluid surrounding the heart) on ultrasound.

Pericarditis typically presents with chest pain that is often worsened by laying backward and relieved by leaning forwards with a pericardial friction rub on auscultation. There are many etiologies including infectious, inflammatory, and post-myocardial infarction pericarditis. The diagnosis can be supported with an ECG and ultrasound. Ultrasound may demonstrate a pericardial effusion (with echogenic fluid around the heart) which is a common complication of pericarditis. The treatment of pericarditis is pain control with medications including NSAIDs, steroids, and colchicine. If the etiology is a post-myocardial infarction pericarditis, aspirin is the mainstay of treatment as medications such as NSAIDs and steroids (in particular) can alter cardiac remodeling.

Figure/Illustration A is an ECG demonstrating diffuse ST elevation (red arrows) with PR depression (blue arrows) with reciprocal PR elevation and ST depression in aVR (yellow circle), which is a classic set of findings in pericarditis.

Incorrect Answers:
Answer 1: Decreased right ventricular contractility with a hyperdynamic left ventricle are the ultrasound findings in a pulmonary embolism. A pulmonary embolism presents with chest pain, dyspnea, hypoxia, signs/symptoms of a deep vein thrombosis (such as lower extremity swelling/tenderness), and risk factors of stasis and hypercoagulability. The obstruction upstream of the right ventricle causes dilation and decreased contractility of the right ventricle while the left ventricle is hyperdynamic in an attempt to compensate for low blood pressure and the poor preload delivered to the left ventricle. Treatment is heparin or thrombolytics in the unstable patient with a massive pulmonary embolism.

Answer 3: Focal ventricular wall motion hypocontractility would be the echocardiograph finding in a myocardial infarction due to infarction in a vascular distribution of the heart. A myocardial infarction would present with chest pain, diaphoresis, dyspnea, and an elevated troponin with ST elevation in a STEMI. This patient’s diffuse ST elevation is not localized to a vascular territory, and his chest pain is positional.

Answer 4: Global hypokinesis of the heart would be seen in a heart failure flare which presents with dyspnea, hypoxia, pulmonary crackles, pulmonary edema on chest radiograph, jugular venous distension, and bilateral pitting lower extremity pitting edema. It would also be seen in Takotsubo cardiomyopathy, which typically presents in a woman after severe emotional stress with chest pain, dyspnea, and decreased global cardiac contractility.

Answer 5: Hyperdynamic right and left ventricular function would be seen in septic shock where systemic vasodilation causes hypotension which is detected by cranial nerve IX (at the carotid bodies) and cranial nerve X (at the aortic arch) leading to a reflex tachycardia and increased cardiac contractility. Hyperdynamic cardiac activity could also be seen in hemorrhagic shock as the heart attempts to compensate for the blood volume loss.

Bullet Summary:
Pericarditis can lead to a pericardial effusion that would present on ultrasound with an echogenic rim of fluid surrounding the heart.