Pericardial Friction Rub
Mark A. Marinella
The pericardial friction rub is the characteristic physical finding of acute pericarditis (AP), the most common disease process involving the pericardium (1).
Approach
When evaluating the patient with a friction rub, it is important to recognize potentially serious causes of AP (Table 7.7).
History
This is a very important element in the evaluation of a friction rub.
A. Pain characteristics. Where is the pain? What is the nature of the pain? Does the pain radiate? Does body position affect the pain? Are systemic symptoms present?
1. The pain of AP is typically precordial and sharp; it can worsen with recumbency, movement, inspiration, coughing, or swallowing.
2. Pain can radiate to the trapezius ridge, a symptom characteristic of AP (1,2).
3. Fever, myalgias, and malaise may be present, especially with viral AP (Chapter 2.6).
B. Other symptoms. AP can complicate several serious diseases. Examples of “red flags” in the history include substernal chest pressure (myocardial infarction), “tearing” pain (aortic dissection), weight loss (malignancy), productive cough (pneumonia with purulent pericarditis), or hemoptysis (tuberculosis). Patients with viral or idiopathic AP typically do not have the aforementioned symptoms.
C. Past medical history. Is there a history of recent pericardiotomy? Is there a history of renal failure or hemodialysis? Has there been a previous diagnosis of collagen vascular disease? Noting any prior illnesses associated with AP may assist in the diagnosis of a rub.
D. Drug history. Drugs associated with AP include hydralazine, procainamide, minoxidil, cromolyn, and isoniazid (2).
Physical examination
A. Vital signs. Fever may be present with viral AP. Hypotension or pulsus paradoxus can occur with a large pericardial effusion or pericardial tamponade. Tachycardia may be caused by fever or tamponade (Chapter 7.12).
B. Cardiac auscultation. A quiet room is essential. The pathognomonic physical finding of AP is the pericardial friction rub that has been likened to creaking leather or a scratching sound (1–3). The rub may be evanescent and vary in intensity; hence, multiple attempts should be made to elicit this finding. The rub is best heard with the stethoscope diaphragm firmly applied to the chest wall at the left-lower sternal border at end-inspiration (2). Having the patient lean forward may be helpful. The classic friction rub occurs in three phases: atrial systole, ventricular systole, and ventricular diastole. However, eliciting all three phases is uncommon. The presence of a rub does not exclude a large pericardial effusion or cardiac tamponade (2,3).
Testing
A. Laboratory tests. AP is mainly a clinical diagnosis but many patients have an elevated erythrocyte sedimentation rate or leukocytosis. Patients with connective tissue disease may have a positive antinuclear antibody test. Creatine phosphokinase or troponin levels can be slightly elevated if the underlying myocardium is inflamed (3).
B. Electrocardiogram. The electrocardiogram (ECG) is the most useful clinical tool in the diagnosis of AP, as repolarization changes occur in up to 90% of patients (1,3). The most sensitive indicator of AP is diffuse, concave-upward ST-segment elevation. A less sensitive, but very specific, indicator of AP is PR-segment depression (2,4). In addition, the P wave and QRS complex are normal and reciprocal changes and Q waves are absent.
1. Later findings of AP include T-wave flattening and T-wave inversion, which typically occur several days after ST-segment elevation.
2. Early repolarization is limited to the precordial leads. Notching of the terminal component of the QRS complex is characteristic of early repolarization.
3. Low-voltage QRS complexes can be a clue to pericardial effusion.
C. Diagnostic imaging. Imaging studies are unnecessary in most patients with idiopathic or classic viral AP. However, if clinical signs of pericardial tamponade or a large effusion are present, echocardiography should be performed (3). Chest radiography may reveal a “water-bottle” heart if a large effusion is present.
Diagnostic assessment
The diagnosis of a pericardial friction rub depends largely on the patient’s history. Chest pain that is sharp, pleuritic, worsened with recumbency, and relieved by leaning forward is very suggestive of pericardial inflammation. Radiation of pain to the trapezius ridge is very characteristic as well. Inquiring about conditions associated with pericarditis is paramount (e.g., autoimmune disease, drugs, recent heart surgery, renal failure). The friction rub is best heard at end-inspiration with the patient leaning forward. The ECG is the most useful diagnostic test, but if there is evidence of cardiac tamponade, an echocardiogram should be obtained.
References
1. Marinella MA. Electrocardiographic manifestations and differential diagnosis of acute pericarditis. Am Fam Physician 1998;57:699–704.
2. Shabeti R. Acute pericarditis. Cardiol Clin 1990;8:639–644.
3. Dehmer GJ, O’Meara JJ. Update on acute pericarditis. Hosp Med 1995;31:39–44.
4. Baljepally R, Spodick DH. PR-segment deviations as the initial electrocardiographic response in acute pericarditis. Am J Cardiol 1998;81:1505–1506.
Pictures
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
Other Book Chapters Related to Pericardial effusion
Read excerpts from these other book chapters related to Pericardial effusion:
Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Pericardial effusion
» Next page: Cardiac tamponade (Handbook of Diseases)
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