Epipericardial fat necrosis as a cause of acute chest pain

Abstract

Acute chest pain is one of the most common reasons for presentation to the emergency department. Although most etiologies of chest pain are easy to clinically ascertain with routine history, physical, and laboratory examinations, we present an important benign cause of acute chest pain that may mimic acute coronary syndrome.

Epipericardial fat necrosis is a rare, non–life-threatening entity that presents as acute chest pain. The diagnosis requires imaging in conjunction with tests to exclude other more common life-threatening causes of chest pain.

CASE REPORT

A 57-year-old woman with prior overactive bladder, migraine headaches, and labyrinthitis presented to her primary care physician with 2 days of chest tightness and generalized chest pain. The patient had undergone bladder surgery 2 weeks prior to presentation. The chest tightness presented abruptly, and the chest pain prevented her from completing her normal physical activity. The pain worsened with deep inspiration. On physical examination, the patient was noted to be splinting on her left side during inspiration. Otherwise, her physical examination and vital signs were unremarkable. Her D-dimer was 1.32 mg/L (normal <0.59 mg/L). Computed tomography (CT) angiogram of the chest demonstrated no evidence of pulmonary embolism but did identify a heterogeneous appearance of the epipericardial and pericardial fat overlying the right ventricle (Figure 1a). Repeat CT of the chest 8 weeks later demonstrated resolution of the anterior mediastinal CT findings (Figure 1b).

Figure 1.

(a) Axial postcontrast CT obtained at presentation. A four-chamber view demonstrates small left pleural effusion, a normal-sized heart, no pericardial effusion, no aortic dissection, and no pulmonary embolism. An ovoid mixed fat and soft attenuation mass is present in the epipericardial fat over the right ventricular apex (arrow). (b) Axial postcontrast image obtained 8 weeks after presentation. The mixed fat attenuation mass has resolved and normal fat is now seen over the right ventricular apex (arrow). No pericardial effusion or other abnormality is present.

DISCUSSION

Acute chest pain is one of the most common presenting symptoms in the emergency department. Major differential considerations remain unstable angina, acute coronary syndrome, aortic dissection, and other noncardiac causes of chest pain such as gastroesophageal reflux disease and costochondritis (1). The differential is broad, but usually the workup is tailored towards diagnosing or ruling out cardiovascular etiologies for chest pain. One uncommon diagnosis that is helpful to keep in the differential is epipericardial fat necrosis, previously known as pericardial or mediastinal fat necrosis (1–3).

Imaging plays a pivotal role in ascertaining this diagnosis and preventing unnecessary workup or procedures. CT remains the modality of choice for diagnosing the necrotic changes in the epipericardial and pericardial fat tissue (3, 4). Magnetic resonance imaging may be utilized for diagnosis (5), but is typically unnecessary. Features of epipericardial fat necrosis include a self-limiting course and typical resolution of findings on repeat imaging (6, 7).

The largest case review series revealed 11 patients from a cohort of 426 patients with acute chest pain caused by epipericardial fat necrosis (4). However, diagnostic dilemmas may underrepresent the actual prevalence of the condition (4).