Jennifer Zhou, MS4Albert Einstein College of MedicineAugust 15, 2012

UT / MR# 02790949

Triage

UT: 25 yo male with chest pain Afebrile, VSS A&O x3 Pain scale: 0

History

HPI Pain onset this AM while doing clerical work

Sharp, stabbing 10/10 substernal pain radiating to back Associated SOB, light-headedness, and diaphoresis Denies n/v Episode lasted 15 minutes

Prior episode of same pain two years ago for which he was hospitalized Recurrence of pain in the past year (1-2 times per

month)

Pt reports usual state of good health in recent weeks

History

PMHx Hospitalized two

years ago for acute pericarditis

PSHx None

Meds None

Allergies NKMA

FHx DM – mother, 2

siblings

SHx Bank employee Denies tobacco,

EtOH, illicit drug use Sexually active with

one partner and uses no contraception

Physical Exam

Vitals BP 130/98 HR 55 T 98.9 RR 16 100% @RA

Gen NAD; sitting up in stretcherNeuro Grossly intactNeck Soft & supple; no JVDCV RRR; S1/S2 noted with no additional

sounds Pain not reproducible with palpationPulm CTABAbd Soft, nontender, nondistended, normal

bowel sounds

Deadly DDx for Chest Pain PET MAC

Pulmonary embolism Esophageal rupture Tension pneumothorax Myocardial infarction Aortic dissection Cardiac tamponade

DDx for UT

PET MAC Angina pectoris Esophagitis GERD Musculoskeletal pain Pericarditis PUD

Labs/Diagnostics

CBC: 5.6> 16.4/46.8 >281

BMP: 139/4.3 100/28 17/1.3 83

Trop: <0.01CPK: 266

CXR: WNL

EKG

Pericardium

Normal Parietal and visceral

layers separated by 20-50mL of plasma ultrafiltrate

Pericarditis Inflammation of

pericardium with infiltration of PMNs

Fibrinous reaction with exudates, adhesions, effusions

Recurrent Pericarditis

15-30% recurrence after resolution of inciting event.

First recurrence usually within 18 months.

Generally not associated with severe complications Low risk of myocardial systolic dysfunction Low risk of effusion and tamponade No reports of association with constrictive

pericarditis

Predictors of Recurrence?No reliable predictors, but….

…individuals who did not respond to out-patient aspirin therapy had higher rates of recurrent pericarditis.

Treatment Options

Aspirin/NSAID for 1-2 weeks Ibuprofen Indomethacin Aspirin

Colchicine for up to 6 months Low dose to avoid GI side effects

+/- Glucocorticoid Second-line Low-moderate dosing with gradual

tapering

Pericardiectomy

2004 ESC Guidelines Class IIa recommendation Indications:

1) More than one recurrence accompanied by cardiac tamponade

2) Recurrence principally manifested by persistent pain despite intensive medical treatment and evidence of glucocorticoid toxicity

Monitoring

ECG CXR Echocardiogram ESR CRP WBC

Take Home Points

1) Recurrent pericarditis is common and not usually caused by reinfection.

2) Colchicine + aspirin/NSAID therapy recommended for prevention; avoid glucocorticoids if possible.

3) Encourage good f/u care.

References

Adler, Y. Recurrent pericarditis. In UpToDate, Basow, DS, UpToDate, Waltham MA, 2012.

Brucato A, Brambilla G, Moreo A, et al. Long-term outcomes in difficult-to-treat patients with recurrent pericarditis. Am J Cardiol 2006; 98:267.

Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol 2004; 43:1042.

Imazio M, Bobbio M, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation 2005; 112:2012.

Imazio M, Bobbio M, Cecchi E, et al. Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial. Arch Intern Med 2005; 165:1987.