Pericarditis v Aortic dissection

[diogotty]

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Hi
Just finished a hard cardio exam and wanted some imput on this Q for peace of mind

Patient presents to the OR with sharp dorsal chest pain (24h onset), dyspnea, BP 80/60 and HR 140. What's the most probable diagnosis:
Acute pericarditis
Aortic dissection

Thanks!

 

[kaleerkalut]

Hi
Just finished a hard cardio exam and wanted some imput on this Q for peace of mind

Patient presents to the OR with sharp dorsal chest pain (24h onset), dyspnea, BP 80/60 and HR 140. What's the most probable diagnosis:
Acute pericarditis
Aortic dissection

Thanks!

Any other details?

 

[diogotty]

Yeah, forgot to mention heart and lung sounds are normal

 

[thehundredthone]

Hi
Just finished a hard cardio exam and wanted some imput on this Q for peace of mind

Patient presents to the OR with sharp dorsal chest pain (24h onset), dyspnea, BP 80/60 and HR 140. What's the most probable diagnosis:
Acute pericarditis
Aortic dissection

Thanks!

Going just by the given information, dorsal chest pain is more indicative of aortic dissection. The low BP can be due to tamponade associated with the dissection.

Also, just to split hairs, technically the dissection can cause acute pericarditis because blood will irritate the pericardium.

Purely epidemiologically speaking though, I don't know which one is more common in a patient of unknown age and comorbidities.

 

[MrBeauregard]

Going just by the given information, dorsal chest pain is more indicative of aortic dissection. The low BP can be due to tamponade associated with the dissection.

Also, just to split hairs, technically the dissection can cause acute pericarditis because blood will irritate the pericardium.

Purely epidemiologically speaking though, I don't know which one is more common in a patient of unknown age and comorbidities.

I'd say aortic dissection. It will present with tearing retrosternal chest pain, hypotension and tachycardia. In the case of aortic dissection, it can involve any artery which branches from it, including the coronary arteries, innominate, left common carotid, left subclavian, and renal(s), just to name a few. It can also involve the pericardium if it is a Type A (proximal) dissection. This is more likely to result in pericardial tamponade with rapidly progressing hypotension, tachycardia, and JVD instead of pericarditis (although thehundrethone certainly is not wrong that blood is an irritant and can lead to inflammation; after all, that's why patients with SAH develop vasospasm and one reason why patients with prior intra-abdominal surgery develop adhesions).

Acute percarditis, by itself and classically speaking, does not cause hypotension (maybe it will cause tachycardia because of beta-adrenergic stimulation as a result of pain). If the pericarditis is complicated by an effusion with resultant pericardial tamponade then hypotension can result. If the patient had normal heart and lung sounds this further leads us away from pericarditis. The absence of a friction rub and distant heart sounds means there is probably no pericardial inflammation and no effusion limiting the sound transfer to the diaphragm of your stethoscope, respectively.

 

[diogotty]

Thanks for all the answers!
I also thought hypotension was the dealbreaker.

 

[evilbooyaa]

No mention of JVP?

And I agree, this sounds like a really bad dissection. Remember that dissection can be caused by sky-high BPs as well (like 170+/110+) and may still be that high if there hasn't been progression into tamponade.

 

[diogotty]

I'll check the exact wording they use when they release the exam next week for review

 

[thehundredthone]

No mention of JVP?

And I agree, this sounds like a really bad dissection. Remember that dissection can be caused by sky-high BPs as well (like 170+/110+) and may still be that high if there hasn't been progression into tamponade.

As per my experience so far with UWorld and other sources, it is more likely that the presentation will be that of an old man with tearing type chest pain and a sky high BP than low BP and JVD, but it's important to recognize that a dissection can cause tamponade.

Acute post-viral pericarditis can present with an effusion leading to tamponade. This will usually be reflected in the history. With pericardial effusion the duration over which fluid accumulates is the difference between tamponade and a bottle shaped cardiac shadow on CXR.

 

[evilbooyaa]

As per my experience so far with UWorld and other sources, it is more likely that the presentation will be that of an old man with tearing type chest pain and a sky high BP than low BP and JVD, but it's important to recognize that a dissection can cause tamponade.

Acute post-viral pericarditis can present with an effusion leading to tamponade. This will usually be reflected in the history. With pericardial effusion the duration over which fluid accumulates is the difference between tamponade and a bottle shaped cardiac shadow on CXR.

The word you're looking for is "Globular" haha.

And yeah, you're right on all points. With no history of a viral illness, no worsening of pain with changes in position, a normal cardiac exam (no pericardial rub) and more retrosternal pain (that is acute <24h), all signs point to dissection for me.