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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.