What is the character of chest pain in pericarditis?

Character of Chest Pain in Pericarditis

Pericarditis classically presents with sharp, pleuritic chest pain that is retrosternal or left precordial, worsens with inspiration and lying supine, and improves when sitting up or leaning forward. 1, 2

Primary Pain Characteristics

The chest pain of pericarditis has several distinctive features that differentiate it from other causes of chest pain:

• Quality: Sharp and pleuritic in nature, rather than the pressure-like or squeezing quality typical of angina 1, 2
• Location: Retrosternal or left precordial, with characteristic radiation to the trapezius ridge (neck, back, or left shoulder) 1, 3, 2
• Positional variation: Pain improves dramatically when sitting upright and leaning forward, and worsens when lying supine 1, 2
• Respiratory variation: Pain increases with inspiration (pleuritic), distinguishing it from ischemic chest pain 1, 4

Frequency and Clinical Context

• This characteristic chest pain pattern occurs in approximately 90% of patients with acute pericarditis 3, 4
• The pain typically builds gradually rather than having sudden onset, though not as slowly as typical angina 1
• Unlike anginal pain, pericarditic chest pain is not precipitated by physical exertion or emotional stress 1

Important Diagnostic Distinctions

Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease and should raise suspicion for acute pericarditis. 1

Key Differentiating Features from Acute Coronary Syndrome:

• Pericarditis: Sharp, pleuritic, positional, radiates to trapezius ridge 1, 2
• Angina/ACS: Pressure-like, builds gradually over minutes, radiates to left arm/jaw, not affected by position or respiration 1

Atypical Presentations Requiring Vigilance:

• When pericarditis involves myocardial inflammation (myopericarditis), the chest pain may include features similar to acute coronary syndromes, including left arm radiation 3
• In myopericarditis, troponin elevation occurs in up to 50% of cases, and the pain pattern may be less clearly positional 1, 3
• Left arm pain in suspected pericarditis should raise suspicion for myocardial involvement and warrants coronary evaluation 3

Clinical Pitfalls to Avoid

• Do not rely on nitroglycerin response as a diagnostic criterion - relief with nitroglycerin can occur with pericarditis and esophageal spasm, not just ischemia 1
• Pain that can be localized to a very limited area or radiates below the umbilicus is unlikely to be pericarditis 1
• Fleeting chest pain lasting only seconds is unlikely to represent pericarditis 1
• The absence of typical positional or pleuritic features does not exclude pericarditis, as these findings may not be present in all cases 1

Diagnostic Confirmation

The diagnosis of acute pericarditis requires at least 2 of 4 criteria, with characteristic chest pain being just one component 1, 2:

• Pericarditic chest pain (as described above)
• Pericardial friction rub on examination
• New widespread ST-elevation or PR depression on ECG
• New or worsening pericardial effusion on imaging

When myocardial involvement is suspected based on atypical pain features (such as left arm radiation) or elevated troponin, cardiac MRI with gadolinium contrast is effective to distinguish myopericarditis from other causes including myocardial infarction. 1, 3