A 47-year-old man comes to the emergency department due to chest pain. He says the pain is sharp and substernal, and it began this morning. Swallowing and deep breathing make the pain worse. The patient reports that 3 days ago he had a sore throat and muscle pains, but these symptoms are currently resolved. His medical history is otherwise unremarkable. The patient does not smoke or consume alcohol. He has no significant history of cardiac disease in his family. Temperature is 37.9 C (100.2 F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are 20/min. There is no tenderness with palpation of the chest wall. During cardiac auscultation, a scratchy sound is heard at the left sternal border just before S1, again between S1 and S2, and then faintly just after S2. The lungs are clear on auscultation. ECG reveals a sinus rhythm with PR segment depression in both precordial and limb leads. Laboratory values are as follows:
| Leukocytes | 9,000/mm3 |
| Creatinine | 0.9 mg/dL |
Which of the following is the most appropriate next step in management of this patient?
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Acute pericarditis |
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NSAIDs = nonsteroidal anti-inflammatory drugs; SLE = systemic lupus erythematosus. |
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This patient most likely has acute viral pericarditis. Most cases of acute pericarditis are thought to be due to viral infection, and many viruses have been implicated (eg, adenovirus, coxsackievirus, echovirus, influenza virus, HIV). Patients typically have sharp chest pain that is worse with deep breathing (pleuritic) or swallowing and may follow several days of a viral prodrome (eg, fatigue, sore throat, myalgias). Auscultation at the left sternal border usually indicates a pericardial friction rub (high-frequency grating or scratching sound) that is often triphasic (occurring during atrial systole, ventricular systole, and early ventricular diastole). ECG characteristically shows diffuse PR depression (due to inflammation of atrial myocardium) and diffuse ST elevation (due to inflammation of ventricular myocardium), but findings can vary. Pericardial effusion is present in >50% of cases.
Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, indomethacin) in combination with colchicine are the preferred treatment for patients with viral (or idiopathic) pericarditis. Colchicine decreases the rate of recurrent pericarditis in these patients.
(Choices A and H) Acute pericarditis is an inflammatory process. Analgesics such as acetaminophen and narcotics (eg, oxycodone) do not have anti-inflammatory properties and therefore do not play a role in management.
(Choice B) Bacterial organisms (eg, staphylococcus, pneumococcus) are rare causes of acute purulent pericarditis, and tuberculosis may cause subacute or chronic pericarditis. This patient's presentation with a viral prodrome is consistent with viral pericarditis, for which antibiotics (eg, azithromycin) do not play a role.
(Choices C and G) Heparin and nitroglycerin are indicated in patients with acute coronary syndrome, which typically presents with nonpleuritic (rather than pleuritic) chest pain.
(Choice E) High-dose (rather than low-dose) aspirin is sometimes used in combination with colchicine in treating acute pericarditis. However, aspirin monotherapy is rarely used.
(Choices F and I) Corticosteroids (eg, prednisone) are used in patients with a contraindication to NSAIDs (eg, renal insufficiency) or failure of combination NSAID/colchicine therapy. They are not used as initial therapy or in combination with NSAIDs (eg, naproxen) in patients with viral pericarditis.
Educational objective:
Patients with acute viral (or idiopathic) pericarditis should be initially treated with a combination of nonsteroidal anti-inflammatory drugs (eg, ibuprofen) and colchicine,
as colchicine lowers the rate of recurrent pericarditis. Corticosteroids (eg, prednisone) are second-line therapy for these patients.