Is left arm pain associated with pericarditis?

Left Arm Pain in Pericarditis

Left arm pain is not a classical symptom of pericarditis, but it can occur in some cases, particularly when pericarditis is associated with myocardial involvement (myopericarditis).

Classical Presentation of Pericarditis

• Pericarditis typically presents with sharp, pleuritic chest pain that is often retrosternal and may improve with sitting up or leaning forward 1
• The chest pain of pericarditis is typically central and can radiate to the neck, back, or left shoulder, but specific left arm radiation is not a classical feature 1, 2
• The hallmark physical finding is a pericardial friction rub, though it is only present in about one-third of cases 2
• Diagnostic criteria include at least 2 of the following: characteristic chest pain, pericardial friction rub, widespread ST-segment elevation with PR depression on ECG, and new or worsening pericardial effusion 3

When Left Arm Pain May Occur in Pericarditis

• In cases of myopericarditis (pericarditis with myocardial involvement), the clinical presentation may include left arm pain similar to that seen in acute coronary syndromes 1
• The 2015 ESC Guidelines note that myopericarditis can present with chest pain that has features of both pericarditis and myocardial ischemia 1
• In a documented case report, a patient with Coxsackie B viral pericarditis presented with substernal chest pain radiating to the left arm and shoulder that improved with leaning forward 4

Differentiating Pericarditis from Myocardial Infarction

• Left arm pain is a classic symptom of myocardial infarction, making differentiation important 1
• In pericarditis, the pain is typically:
  • Sharp and pleuritic (worsens with inspiration)
  • Changes with posture (improves with sitting forward)
  • More diffuse and may be accompanied by a friction rub 1, 2
• Electrocardiographic differences are crucial:
  • Pericarditis: widespread concave ST elevation and PR depression
  • Myocardial infarction: localized convex ST elevation 1, 3
• Elevated troponin levels may be present in both conditions, but in pericarditis this indicates myocardial involvement (myopericarditis) 1

Diagnostic Approach When Left Arm Pain is Present

• Coronary angiography is recommended in cases of pericarditis with suspected myocardial involvement to rule out acute coronary syndromes, especially when left arm pain is a prominent feature 1
• Cardiac MRI with gadolinium contrast is effective to distinguish myopericarditis from other causes, including myocardial infarction with nonobstructive coronary arteries 1
• Transthoracic echocardiography is recommended to assess for pericardial effusion, ventricular wall motion abnormalities, and other cardiac findings 1

Clinical Implications

• The presence of left arm pain in a patient with suspected pericarditis should raise suspicion for myocardial involvement 1
• Hospitalization is recommended for diagnosis and monitoring of patients with suspected myopericarditis, especially when presenting with atypical features like left arm pain 1
• Treatment approach may need modification when myocardial involvement is suspected, as some authors recommend reducing NSAID dosages in myopericarditis compared to pure pericarditis 1

Common Pitfalls

• Misdiagnosing pericarditis with left arm pain as acute coronary syndrome, leading to unnecessary interventions 1
• Failing to recognize myocardial involvement in pericarditis when left arm pain is present 1
• Overlooking the possibility of concurrent pericarditis and myocardial infarction, which can occur simultaneously 1
• Relying solely on ECG findings without comprehensive assessment including echocardiography and cardiac biomarkers 1