From the Guidelines
Leaning forward is a classic posture that often relieves chest pain in patients with pericarditis, as it reduces pressure on the inflamed pericardium. Pericarditis is characterized by inflammation of the pericardium, the sac surrounding the heart, and typically causes sharp, pleuritic chest pain that may be improved by sitting up or leaning forward, as noted in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1. This guideline, published in the Journal of the American College of Cardiology, highlights that pericarditis classically presents with chest pain that is sharp and may be improved by sitting up or leaning forward.
When a patient leans forward, especially while sitting up, it decreases the contact between the inflamed pericardial layers, thereby reducing pain. This characteristic pain relief with forward posture is known as Levine's sign and is considered a classic clinical feature of pericarditis. For patients experiencing pericarditis pain, finding positions that provide comfort, such as sitting upright and leaning forward, can help manage symptoms while medical treatment addresses the underlying inflammation.
- Key features of pericarditis include:
- Sharp, pleuritic chest pain
- Pain improved by sitting up or leaning forward
- Pericardial friction rub may be audible
- Widespread ST-elevation with PR depression on electrocardiogram
- Treatment typically includes NSAIDs, sometimes with colchicine to prevent recurrence, as per the guideline 1. Severe cases may require corticosteroids, but these are generally reserved for refractory cases due to the potential for rebound symptoms.
From the Research
Pericarditis Symptoms and Relief
- Pericarditis is characterized by pleuritic-type chest pain that radiates to the left shoulder and may be relieved by leaning forward 2, 3.
- The pain is often described as acute, sharp, and retrosternal, and is typically relieved by sitting or leaning forward 3.
Treatment and Management
- First-line treatment for pericarditis includes nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine 3, 4.
- Glucocorticoids are reserved for severe or refractory cases, or in cases where the cause of pericarditis is likely connective tissue disease, autoreactivity, or uremia 3, 4.
- Immunosuppressive agents, such as azathioprine, methotrexate, and mycophenolate mofetyl, may be used as second-line therapy in patients with idiopathic recurrent pericarditis unresponsive to corticosteroids 5.
Clinical Features and Diagnosis
- A pericardial friction rub is found in up to 85% of patients with acute pericarditis 3.
- Classic electrocardiographic changes include widespread concave upward ST-segment elevation without reciprocal T-wave inversions or Q waves 3.
- Chest radiographs, Doppler studies, and laboratory tests confirm the diagnosis and provide information about the degree of effusion 2.