What does chest pain relieved with prednisone (corticosteroid) indicate?

Chest Pain Relief with Prednisone: Diagnostic Implications

Chest pain that improves with prednisone most strongly suggests pericarditis, particularly of inflammatory or autoimmune etiology. This response pattern is a key diagnostic clue that should prompt specific evaluation and management.

Primary Causes of Prednisone-Responsive Chest Pain

1. Pericarditis

• Acute pericarditis is the most common inflammatory cardiac condition that responds well to corticosteroids 1
• Characterized by:
  • Sharp, retrosternal, pleuritic chest pain that may worsen when lying supine and improve when leaning forward 2
  • Pain typically increases with inspiration 2
  • May be accompanied by a pericardial friction rub on examination 2
  • ECG findings often include widespread ST-segment elevation 1
  • Pericardial effusion may be present on echocardiography 1

2. Specific Etiologies of Pericarditis That Respond to Prednisone

Autoimmune Pericarditis

• Systemic lupus erythematosus (SLE) and other autoimmune conditions can cause pericarditis 3
• In SLE, chest pain may be accompanied by fever, fatigue, arthralgias, and hematologic abnormalities 3
• Responds particularly well to corticosteroid therapy 3

Tuberculous Pericarditis

• Prednisone (0.5-1.0 mg/kg daily) is recommended in severe cases 2
• Significantly reduces mortality (2% vs 14% without prednisone) 2
• Reduces need for repeated pericardiocentesis 2
• Should be given with concurrent antituberculous therapy 2

Post-COVID-19 Myocarditis/Pericarditis

• Inflammatory cardiac involvement following COVID-19 may respond to corticosteroids 2
• Patients with hemodynamic compromise or MIS-A (multisystem inflammatory syndrome in adults) may benefit from IV corticosteroids 2

Histoplasmosis-Related Pericarditis

• Prednisone (0.5-1.0 mg/kg daily in tapering doses over 1-2 weeks) is recommended in severe cases 2
• Concurrent antifungal therapy (itraconazole) should be given if corticosteroids are administered 2

Diagnostic Approach

Initial Evaluation

1. ECG: Look for diffuse ST elevations (unlike the localized changes of myocardial infarction) 2
2. Echocardiogram: Assess for pericardial effusion or wall motion abnormalities 2
3. Laboratory tests:
   • Cardiac troponin to rule out myocardial injury
   • Inflammatory markers (ESR, CRP)
   • Autoimmune panel if suspected (ANA, RF, anti-CCP) 2

Advanced Testing (Based on Clinical Suspicion)

• Cardiac MRI: Particularly useful for suspected myocarditis or pericarditis 2
• Specific testing for tuberculosis, histoplasmosis, or other infectious causes if clinically indicated 2

Management Algorithm

1. For mild pericarditis:

   • First-line: NSAIDs plus colchicine 1
   • Add prednisone if inadequate response or contraindications to NSAIDs

2. For moderate to severe pericarditis:

   • Prednisone 0.5-1.0 mg/kg/day (typically 30-60 mg daily) 2
   • Taper over 2-6 weeks based on clinical response
   • Consider colchicine addition to prevent recurrence 2

3. For suspected tuberculous pericarditis:

   • Prednisone 60 mg/day for 4 weeks, then 30 mg/day for 4 weeks, 15 mg/day for 2 weeks, and 5 mg/day for 1 week 2
   • Must be given with appropriate anti-tuberculous therapy 2

4. For autoimmune-related pericarditis:

   • Higher dose prednisone may be required (1 mg/kg/day) 2
   • Consider steroid-sparing agents for long-term management 2

Important Clinical Pearls

• Response to prednisone does not establish a definitive diagnosis but narrows the differential to inflammatory conditions
• Chest pain that is fleeting (lasting only seconds) is unlikely to be cardiac in origin, even if it responds to prednisone 4
• In patients with immune checkpoint inhibitor therapy, chest pain relieved by prednisone may indicate immune-related myocarditis or pericarditis requiring prompt intervention 2
• For recurrent episodes of pericarditis responsive to prednisone, consider underlying autoimmune disease or chronic/relapsing pericarditis 2

Potential Pitfalls

• Do not assume all chest pain relieved by prednisone is benign - underlying serious conditions like tuberculosis or malignancy may be present
• Do not fail to investigate for specific causes of pericarditis, particularly in high-risk populations
• Do not discontinue prednisone abruptly; always taper to prevent recurrence
• Do not use prednisone alone for infectious pericarditis without appropriate antimicrobial coverage 2
• Do not delay cardiac imaging in patients with persistent or recurrent symptoms despite prednisone therapy 2