A Descriptive Analysis of ED Diagnosed Acute Pericarditis
A Descriptive Analysis of ED Diagnosed Acute Pericarditis
Two hundred and forty presentations, comprising 220 patients, were identified by the EDIS search as an ED diagnosis of pericarditis, pericardial effusion, pneumopericardium or pericardial tamponade. Of these, 41 were excluded as they were incorrectly coded, had an ED diagnosis other than pericarditis or did not represent acute pericarditis on review of the medical record. A further 20 sets of medical records could not be obtained, leaving 179 episodes (161 patients) suitable for analysis.
Inter-rater reliability analysis of past medical history showed 97.7% agreement (11 variables) and mean κ 0.95; symptoms 75.8% agreement (15 variables) and mean κ 0.76; physical signs 89.1% agreement (eight variables); and investigation interpretation 83.3% agreement (12 variables).
In those patients with an ED diagnosis of acute pericarditis, the mean age was 38.8 (SD 17.4) years and 119/161 (73.9% (95% CI 66.4% to 81.5%)) were men. Mean age of the index presentation for male patients was 37.0 years (SD 16.0) compared with 44.1 years (SD 20.2) for female patients (p=0.043). Of the 179 presentations, 32 (17.9% (95% CI 12.6% to 24.3%)) were representations following a previous diagnosis of pericarditis in the same hospital.
The patients as a group were relatively healthy with hypertension being the most common past medical illness (8.1% (95% CI 4.6% to 13.1%)), followed by ischaemic heart disease (3.7% (95% CI 1.5% to 7.6%)) and rheumatological disease (3.7% (95% CI 1.5% to .6%)). Nineteen patients (11.8% (95% CI 7.3% to 17.8%)) disclosed a past history of pericarditis and one patient had previous myocarditis.
Table 1 describes the clinical characteristics of each presentation. Most presentations had pleuritic chest pain worse with inspiration but only half of the documented pain was characterised as sharp or stabbing, with an equal number reporting dull or other chest pain (tightness, cramping). The classically described pain radiation to the left shoulder and arm was uncommon although a change of pain with posture was documented in nearly half the cases. Other clinical features were poorly documented.
Duration of symptoms prior to ED presentation ranged from less than 1 h to 3 weeks although one patient had symptoms for 4 months, and another for 1 year. Eighty-three presentations (46.4% (95% CI 38.9% to 54.0%)) occurred within 1 day of symptom onset, 37 (20.7% (95% CI 15.0% to 27.4%)) between 1–2 days, 38 between 3 days and 2 weeks (21.2% (95% CI 15.5% to 27.9)), 11 presented greater than 2 weeks (6.1% (95% CI 3.1% to 10%)), and 11 did not have symptom duration recorded.
Only seven of 173 presentations with a documented temperature (4.0% (95% CI 1.6% to 8.1%)) had a temperature greater than 38°C in the ED, 2/169 (1.2% (95% CI 0.1% to 4.2%)) had a systolic blood pressure of less than 90 mm Hg recorded, and 8/107 (7.5% (95% CI 3.3% to 14.2%)) recorded an elevated jugular venous pressure (JVP). Tachycardia with heart rate greater than 100/min (21.8% (95% CI 16.0% to 28.6%)) and respiratory rate greater than 20/min (15.7% (95% CI 10.7% to 21.9%)) were more common, but no hypoxia was recorded. A pericardial rub was noted in 19 presentations (19.4% (95% CI 12.1% to 28.6%)) and was documented as being absent in 79 presentations.
All presentations in the study had an ECG performed and all but one was available for review in the medical records. The record with no ECG available documented ST-segment elevation in the medical notes. Findings are presented in Table 2.
Requested laboratory investigations varied considerably between patients as described in Table 3. Troponin levels were abnormal in only 10 of 156 presentations tested initially (6.4% (95% CI 3.1% to 11.5%)) with a further two abnormal results on serial testing. Thyroid function testing demonstrated a single case of hyperthyroidism, and blood cultures showed only a single false positive result. The majority of viral serology and autoantibody testing was negative, but the most common finding was a positive rheumatoid factor in 10 (83.3% (95% CI 51.5% to 97.9%)) of 12 presentations tested.
Chest radiography was performed in 162 presentations (90.5% (95% CI 85.2% to 94.5%)), of which 121 (74.7% (95% CI 67.3% to 81.2%)) were reported as normal. Table 4 describes the reported abnormalities which included some diagnoses which may have been the cause for the patients' presentations, including pneumothorax, pneumomediastinum and lung consolidation.
Echocardiography reports were available for review in 57 (31.8% (95% CI 25.0% to 39.2%) presentations. Of those performed, 32 (56.1% (95% CI 42.3% to 69.2%)) were normal and a pericardial effusion was seen in 17 studies (29.8% (95% CI 18.4% to 43.4%)). Although most effusions were small or trivial in size, two cases had evidence of right atrial diastolic collapse.
Treatment details were recorded in 173 (96.6% (95% CI 92.8% to 98.7%)) presentations. The most frequent medications used were NSAIDs, which were given in 84.4% (95% CI 78.1% to 89.5%) of cases. Colchicine was used in only 14 cases (8.1% (95% CI 4.5% to 13.2%)), of which two were repeat presentations. Twelve of the patients treated with colchicine were admitted to hospital under the care of inpatient teams. A wide variety of other medications were used in 46 (26.6% (95% CI 20.2% to 33.8%)) presentations, including antacids, anticoagulants, antianginal agents and antibiotics. Three patients were given corticosteroids. No patients required pericardiocentesis in the ED.
The underlying cause of pericarditis was not defined, or was documented as idiopathic in 134 (74.8% (95% CI 67.8% to 81.0%)) of cases in this study. A presumed viral pericarditis was recorded in 31 patients (17.3% (95% CI 12.1% to 23.7%)), and a further 14 patients (7.8% (95% CI 4.3% to 12.7%)) had another cause for their disease documented in the medical record. These included post cardiovascular procedure, malignancy, radiation, autoimmune and drug related pathology.
The majority of cases (70.4% (95% CI 63.1% to 77.0%)) were discharged directly from the ED with a further four (2.2% (95% CI 0.6% to 5.6%)) discharged after an admission to the ED observation ward. Recommended follow-up was recorded in 142 cases (79.3% (95% CI 72.6% to 85.0%)) and was predominantly with the patient's general practitioner (65.5% (95% CI 57.1% to 73.3%).
Further data analyses were performed, comparing patient disposition, sex, age and risk factors previously associated with more severe disease states. These risk factors are listed in the footnote of Table 5.
Dividing the patients into two groups based on those with or without more than one risk factor demonstrated significant differences as listed in Table 5. Using greater than one risk factor as a measure has 54.2% sensitivity for admission and 82.4% specificity for discharge. Alternatively, using any one risk factor has 77.1% sensitivity for admission and 35.1% specificity for discharge.
The analysis of admitted versus discharged patients revealed a number of significant differences in clinical and investigation findings as demonstrated in Table 6. Treatment differences between admitted and discharged patients showed significant increased use of colchicine, antacids, paracetamol or opioid analgesia in the admitted group. This may represent an increased severity of disease, or alternatively, in the case of antacid and analgesic use, a diagnostic uncertainty which may have contributed towards admission.
Comparison of patients based on age showed those aged 40 years or older were the only patients with comorbid conditions and were more likely to be admitted. This patient subset was significantly more likely to have chest crackles on examination, describe retrosternal pain and an atypical tight or cramping character of pain. Colchicine or anti-anginal medications were more likely to be prescribed for the older group. Younger patients are more likely to be discharged than older patients (figure 1).
(Enlarge Image)
Figure 1.
Comparison of admissions per decade of age.
Analysis of patient gender revealed that men were more likely to have an abnormal ECG (although less likely to have ST elevation), anti-anginal therapy and cardiology review, despite having a lower mean age than female patients.
Results
Two hundred and forty presentations, comprising 220 patients, were identified by the EDIS search as an ED diagnosis of pericarditis, pericardial effusion, pneumopericardium or pericardial tamponade. Of these, 41 were excluded as they were incorrectly coded, had an ED diagnosis other than pericarditis or did not represent acute pericarditis on review of the medical record. A further 20 sets of medical records could not be obtained, leaving 179 episodes (161 patients) suitable for analysis.
Inter-rater reliability analysis of past medical history showed 97.7% agreement (11 variables) and mean κ 0.95; symptoms 75.8% agreement (15 variables) and mean κ 0.76; physical signs 89.1% agreement (eight variables); and investigation interpretation 83.3% agreement (12 variables).
Demographic Characteristics and Background
In those patients with an ED diagnosis of acute pericarditis, the mean age was 38.8 (SD 17.4) years and 119/161 (73.9% (95% CI 66.4% to 81.5%)) were men. Mean age of the index presentation for male patients was 37.0 years (SD 16.0) compared with 44.1 years (SD 20.2) for female patients (p=0.043). Of the 179 presentations, 32 (17.9% (95% CI 12.6% to 24.3%)) were representations following a previous diagnosis of pericarditis in the same hospital.
The patients as a group were relatively healthy with hypertension being the most common past medical illness (8.1% (95% CI 4.6% to 13.1%)), followed by ischaemic heart disease (3.7% (95% CI 1.5% to 7.6%)) and rheumatological disease (3.7% (95% CI 1.5% to .6%)). Nineteen patients (11.8% (95% CI 7.3% to 17.8%)) disclosed a past history of pericarditis and one patient had previous myocarditis.
Clinical Presentation
Table 1 describes the clinical characteristics of each presentation. Most presentations had pleuritic chest pain worse with inspiration but only half of the documented pain was characterised as sharp or stabbing, with an equal number reporting dull or other chest pain (tightness, cramping). The classically described pain radiation to the left shoulder and arm was uncommon although a change of pain with posture was documented in nearly half the cases. Other clinical features were poorly documented.
Duration of symptoms prior to ED presentation ranged from less than 1 h to 3 weeks although one patient had symptoms for 4 months, and another for 1 year. Eighty-three presentations (46.4% (95% CI 38.9% to 54.0%)) occurred within 1 day of symptom onset, 37 (20.7% (95% CI 15.0% to 27.4%)) between 1–2 days, 38 between 3 days and 2 weeks (21.2% (95% CI 15.5% to 27.9)), 11 presented greater than 2 weeks (6.1% (95% CI 3.1% to 10%)), and 11 did not have symptom duration recorded.
Physical Examination
Only seven of 173 presentations with a documented temperature (4.0% (95% CI 1.6% to 8.1%)) had a temperature greater than 38°C in the ED, 2/169 (1.2% (95% CI 0.1% to 4.2%)) had a systolic blood pressure of less than 90 mm Hg recorded, and 8/107 (7.5% (95% CI 3.3% to 14.2%)) recorded an elevated jugular venous pressure (JVP). Tachycardia with heart rate greater than 100/min (21.8% (95% CI 16.0% to 28.6%)) and respiratory rate greater than 20/min (15.7% (95% CI 10.7% to 21.9%)) were more common, but no hypoxia was recorded. A pericardial rub was noted in 19 presentations (19.4% (95% CI 12.1% to 28.6%)) and was documented as being absent in 79 presentations.
Investigations
All presentations in the study had an ECG performed and all but one was available for review in the medical records. The record with no ECG available documented ST-segment elevation in the medical notes. Findings are presented in Table 2.
Requested laboratory investigations varied considerably between patients as described in Table 3. Troponin levels were abnormal in only 10 of 156 presentations tested initially (6.4% (95% CI 3.1% to 11.5%)) with a further two abnormal results on serial testing. Thyroid function testing demonstrated a single case of hyperthyroidism, and blood cultures showed only a single false positive result. The majority of viral serology and autoantibody testing was negative, but the most common finding was a positive rheumatoid factor in 10 (83.3% (95% CI 51.5% to 97.9%)) of 12 presentations tested.
Chest radiography was performed in 162 presentations (90.5% (95% CI 85.2% to 94.5%)), of which 121 (74.7% (95% CI 67.3% to 81.2%)) were reported as normal. Table 4 describes the reported abnormalities which included some diagnoses which may have been the cause for the patients' presentations, including pneumothorax, pneumomediastinum and lung consolidation.
Echocardiography reports were available for review in 57 (31.8% (95% CI 25.0% to 39.2%) presentations. Of those performed, 32 (56.1% (95% CI 42.3% to 69.2%)) were normal and a pericardial effusion was seen in 17 studies (29.8% (95% CI 18.4% to 43.4%)). Although most effusions were small or trivial in size, two cases had evidence of right atrial diastolic collapse.
Treatment
Treatment details were recorded in 173 (96.6% (95% CI 92.8% to 98.7%)) presentations. The most frequent medications used were NSAIDs, which were given in 84.4% (95% CI 78.1% to 89.5%) of cases. Colchicine was used in only 14 cases (8.1% (95% CI 4.5% to 13.2%)), of which two were repeat presentations. Twelve of the patients treated with colchicine were admitted to hospital under the care of inpatient teams. A wide variety of other medications were used in 46 (26.6% (95% CI 20.2% to 33.8%)) presentations, including antacids, anticoagulants, antianginal agents and antibiotics. Three patients were given corticosteroids. No patients required pericardiocentesis in the ED.
Cause
The underlying cause of pericarditis was not defined, or was documented as idiopathic in 134 (74.8% (95% CI 67.8% to 81.0%)) of cases in this study. A presumed viral pericarditis was recorded in 31 patients (17.3% (95% CI 12.1% to 23.7%)), and a further 14 patients (7.8% (95% CI 4.3% to 12.7%)) had another cause for their disease documented in the medical record. These included post cardiovascular procedure, malignancy, radiation, autoimmune and drug related pathology.
Disposition and Follow Up
The majority of cases (70.4% (95% CI 63.1% to 77.0%)) were discharged directly from the ED with a further four (2.2% (95% CI 0.6% to 5.6%)) discharged after an admission to the ED observation ward. Recommended follow-up was recorded in 142 cases (79.3% (95% CI 72.6% to 85.0%)) and was predominantly with the patient's general practitioner (65.5% (95% CI 57.1% to 73.3%).
Comparative Analyses
Further data analyses were performed, comparing patient disposition, sex, age and risk factors previously associated with more severe disease states. These risk factors are listed in the footnote of Table 5.
Dividing the patients into two groups based on those with or without more than one risk factor demonstrated significant differences as listed in Table 5. Using greater than one risk factor as a measure has 54.2% sensitivity for admission and 82.4% specificity for discharge. Alternatively, using any one risk factor has 77.1% sensitivity for admission and 35.1% specificity for discharge.
The analysis of admitted versus discharged patients revealed a number of significant differences in clinical and investigation findings as demonstrated in Table 6. Treatment differences between admitted and discharged patients showed significant increased use of colchicine, antacids, paracetamol or opioid analgesia in the admitted group. This may represent an increased severity of disease, or alternatively, in the case of antacid and analgesic use, a diagnostic uncertainty which may have contributed towards admission.
Comparison of patients based on age showed those aged 40 years or older were the only patients with comorbid conditions and were more likely to be admitted. This patient subset was significantly more likely to have chest crackles on examination, describe retrosternal pain and an atypical tight or cramping character of pain. Colchicine or anti-anginal medications were more likely to be prescribed for the older group. Younger patients are more likely to be discharged than older patients (figure 1).
(Enlarge Image)
Figure 1.
Comparison of admissions per decade of age.
Analysis of patient gender revealed that men were more likely to have an abnormal ECG (although less likely to have ST elevation), anti-anginal therapy and cardiology review, despite having a lower mean age than female patients.
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