Jennifer Zhou MS 4 Albert Einstein College of

Jennifer Zhou, MS 4 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 x 3 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, Et. OH, 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 stretcher Neuro Grossly intact Neck Soft & supple; no JVD CV RRR; S 1/S 2 noted with no additional sounds Pain not reproducible with palpation Pulm CTAB Abd 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: CPK: <0. 01 266 CXR: WNL

EKG

Pericardium Normal Parietal and visceral layers separated by 2050 m. L 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 outpatient 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 Up. To. Date, Basow, DS, Up. To. Date, 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.