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EM Case Presentation

Jennifer Zhou, MS4 Albert Einstein College of Medicine August 15, 2012. EM Case Presentation. 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

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EM Case Presentation

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  1. Jennifer Zhou, MS4 Albert Einstein College of Medicine August 15, 2012 EM Case Presentation UT / MR# 02790949

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

  3. 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

  4. 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

  5. Physical Exam Gen • NAD; sitting up in stretcher • Neuro • Grossly intact • Neck • Soft & supple; no JVD • CV • RRR; S1/S2 noted with no additional sounds • Pain not reproducible with palpation • Pulm • CTAB • Abd • Soft, nontender, nondistended, normal bowel sounds Vitals • BP 130/98 • HR 55 • T 98.9 • RR 16 • 100% @RA

  6. Deadly DDx for Chest Pain • PET MAC • Pulmonary embolism • Esophageal rupture • Tension pneumothorax • Myocardial infarction • Aortic dissection • Cardiac tamponade

  7. DDx for UT • PET MAC • Angina pectoris • Esophagitis • GERD • Musculoskeletal pain • Pericarditis • PUD

  8. Labs/Diagnostics CBC: 5.6> 16.4/46.8 >281 BMP: 139/4.3 100/28 17/1.3 83 Trop: <0.01 CPK: 266 CXR: WNL

  9. EKG

  10. 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

  11. 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

  12. Predictors of Recurrence? No reliable predictors, but…. …individuals who did not respond to out-patient aspirin therapy had higher rates of recurrent pericarditis.

  13. 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

  14. Pericardiectomy 2004 ESC Guidelines • Class IIa recommendation • Indications: • More than one recurrence accompanied by cardiac tamponade • Recurrence principally manifested by persistent pain despite intensive medical treatment and evidence of glucocorticoid toxicity

  15. Monitoring • ECG • CXR • Echocardiogram • ESR • CRP • WBC

  16. Take Home Points • Recurrent pericarditis is common and not usually caused by reinfection. • Colchicine + aspirin/NSAID therapy recommended for prevention; avoid glucocorticoids if possible. • Encourage good f/u care.

  17. 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 CollCardiol 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 REcurrentpericarditis) trial. Arch Intern Med 2005; 165:1987.

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