Pericardial disease: Clinical

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Pericardial disease: Clinical

USMLE® Step 2 questions

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A 45-year-old man is brought to the emergency department due to recent onset of chest pain. Initially, he felt chest discomfort that progressed to sharp chest pain, rated as 7/10 in intensity, with radiation to the upper back. He reports that one week ago he recovered from an upper respiratory infection that resolved without treatment. Medical history is significant for diabetes mellitus type 2 and hyperlipidemia. He has been smoking half-a-pack of cigarettes daily for 15 years. Temperature is 38.0°C (100.4°F), pulse is 100/min, respirations are 20/min, and blood pressure is 135/85 mmHg. On physical examination, the patient is in acute distress due to pain and is sweating profusely. An ECG is performed and is shown below:  

Reproduced from: Wikimedia Commons  

Which of the following interventions is the most appropriate for this patient’s condition?  


The pericardium is a sac that covers the heart and the roots of the great vessels.

The pericardium has two layers, an inner serous layer and an outer fibrous layer, and the space between the two layers is the pericardial cavity.

The pericardial cavity is normally filled with about 50 mL of serous fluid that cushions the heart from any kind of external jerk or shock - like a shock absorber.

The pericardium also fixes the heart to the mediastinum, to prevent it from twisting, so that the big vessels don’t get pinched shut.

Pericardial disease is inflammation of the pericardium due to a variety of causes - from infections, to autoimmune disorders, cancer, and trauma.

In pericarditis, the pericardium is inflamed and irritated.

If the inflammation leads to the accumulation of excess fluid in the pericardial sac then it’s called a pericardial effusion, and in its worst form, that extra fluid can cause tamponade physiology.

Finally, there’s constrictive pericarditis, which is where the inflammation is chronic and leads to fibrosis.

In pericarditis, the two inflamed layers of the pericardium rub against one another every time the heart beats. This causes severe, sharp retrosternal chest pain, that radiates to the neck, shoulders, and back, and it typically happens with each breath during inspiration.

That’s because in inspiration the lungs expand, filling the thoracic cavity and compressing the pericardium.

The pain typically worsens when a person is supine and improves when a person is sitting upright and leaning forward.

Upon auscultation, there’s a pericardial friction rub, which is a scratchy, grating, high-pitched rub resembling the sound of leather-on-leather rubbing against each other.

On ECG, there’s widespread ST segment elevation in several leads, which distinguishes it from the ST elevation in myocardial infarction which is only present in the leads that correspond to the infarcted tissue.


Pericardial disease refers to any medical condition that affects the pericardium, the thin sac that surrounds the heart. Common pericardial diseases include pericarditis, which refers to when it's inflamed; pericardial effusion referring to a buildup of fluid in the pericardial sac; and cardiac tamponade, which is a life-threatening condition that results from excessive fluid buildup in the pericardium that prevents the heart from working properly.

Depending on the specific condition, symptoms of the pericardial disease may include chest pain, shortness of breath, rapid or irregular heartbeat, hypotension, and muffled heart sounds. Treatment may involve medications to reduce inflammation or remove excess fluid, pericardiocentesis, or surgery.


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