Review Question - QID 102973

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Pericarditis Treatment Medical QID: 102973 (M3.CV.15.32)

QID 102973 (Type "102973" in App Search)

A 59-year-old woman presents to the emergency department with severe chest pain and shortness of breath. She reports that she was walking in her house when the pain began and it worsened when she laid down to go to bed later in the evening. She experiences relief of the chest pain when she sits down and leans forward with her chest over her knees. She was discharged from the hospital earlier today after suffering from an ST-elevation myocardial infarction 2 weeks that was successfully treated with coronary revascularization. Her past medical history is significant for hypertension and rheumatoid arthritis. Her temperature is 97.9°F (36.6°C), blood pressure is 155/105 mm Hg, pulse is 90/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical examination is significant for a friction rub on cardiac auscultation and an estimated jugular venous pressure of 11 cm H2O. An electrocardiogram is obtained and shown in Figure A. An echocardiogram is obtained and reveals good contractile function of the heart with an ejection fraction of 60% as well as the finding shown in Figure B. A chest radiograph reveals a cardiac silhouette within normal limits. Which of the following is the best management of this patient's condition?

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Aspirin

50%

3/6

Pericardial window

17%

1/6

Pericardiectomy

0/6

Pericardiocentesis

33%

2/6

Prednisone

0/6

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This patient is suffering from acute early pericarditis after a heart attack. High-dose aspirin is the recommended first-line treatment for this condition.

Acute pericarditis is inflammation of the pericardium that often leads to a pericardial effusion. Patients will present with chest pain (worse when supine and relieved with leaning forward), a pericardial friction rub on auscultation, and ECG changes (diffuse ST segment elevation with PR segment depression). The cause is most commonly idiopathic; however, etiologies can include SLE, uremia, viral infection, tuberculosis, rheumatoid arthritis, cancer, medications, radiation, scleroderma, post-MI healing, and post-cardiac surgery. In post-MI acute pericarditis, both NSAIDs and steroids should be avoided to prevent interference with ventricular healing/remodeling. For this reason, aspirin is the preferred first-line medication.

Figure/Illustration A is an EKG showing diffuse ST-segment elevation with PR depression (blue arrows) that is characteristic of a patient with acute pericarditis. Figure/Illustration B shows an echocardiogram of a patient with a pericardial effusion (red arrows). A pericardial effusion is a non-sensitive but specific finding that can be seen in pericarditis and occurs due to inflammatory changes.

Incorrect Answers:
Answer 2: Pericardial window would be indicated either in a stable patient with a large pericardial effusion that is recurrent or not resorbing or in cardiac tamponade after pericardiocentesis has been performed to stabilize the patient.

Answer 3: Pericardiectomy would be indicated to treat constrictive pericarditis but would not be the best initial step in management in pericarditis.

Answer 4: Pericardiocentesis is the best initial step in management in cardiac tamponade which presents with JVD, hypotension, tachycardia, and electrical alternans on ECG. It is an emergent procedure to stabilize the patient.

Answer 5: Prednisone may relieve symptoms in pericarditis; however, in the post MI period it may alter cardiac remodeling making it a less optimal treatment.

Bullet Summary:
The treatment of pericarditis after a MI is high-dose aspirin.

ILLUSTRATIONS:

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