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Naproxen
12%
8/64
Colchicine
2%
1/64
Hemodialysis
41%
26/64
Pericardiocentesis
31%
20/64
Coronary angiography
9%
6/64
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This patient's presentation is most consistent with uremic pericarditis, which is an indication for emergent hemodialysis. Uremic pericarditis is seen in 6-10 percent of patients with chronic renal failure. It is an indication for the initiation of dialysis or the intensification of dialysis for patients already on dialysis. The clinical presentation of uremic pericarditis is similar to pericarditis of other etiologies, except that it is associated with BUN levels of above 60 mg/dL. Most patients' symptoms and size of the pericardial effusion improve with dialysis. The pericardial fluid in uremic pericarditis tends to be hemorrhagic. Unlike in inflammatory causes of pericarditis, the EKG in uremic pericarditis does not show diffuse ST elevation due to a lack of inflammatory cells penetrating the myocardium. Tingle et al. discuss the diagnosis of acute pericarditis, which may be caused by viral infection, many diseases, drugs, invasive cardiac procedures, and chest trauma. A history of abrupt-onset chest pain, the presence of a pericardial friction rub, and electrocardiographic changes such as PR-segment depression and upwardly concave ST-segment elevation. Although highly specific for pericarditis, the pericardial friction rub is often absent or transient. Auscultation during end expiration with the patient sitting up and leaning forward increases the likelihood of observing this physical finding. Meyer and Hostetter discuss the treatment of uremia. Absolute indications for renal replacement therapy in end stage renal disease are as follows: 1) fluid overload or 2) hyperkalemia unresponsive to medical treatment, 3) uremic pericarditis, and 4) refractory metabolic acidosis. Relative indications include 1) glomerular filtration rate < 10 mL/min, 2) serum creatinine > 8 mg/dL, and severe uremic symptoms (seizure, coma). Image A shows an electrocardiogram of a patient with atrial fibrillation. Note the absence of diffuse ST-elevation, PR depression, or ischemic changes. Image B shows the chest radiograph of a patient with a pericardial effusion. Note the enlarged cardiac silhouette. Image C is an echocardiogram of a patient with a pericardial effusion, which is indicated with a white arrow. Incorrect Answers: Answer 1 and 2: NSAIDs and colchicine are the first line of therapy in most cases of pericarditis, but are less successful with uremic pericarditis. Answer 4: Pericardiocentesis is indicated for pericardial tamponade. However, this patient has no signs of tamponade (pulses paradoxus, hypotension, distended neck veins, muffled heart sounds). Answer 5: Coronary angiography would be indicated for evaluation of an ST-elevation myocardial infarction, which is not consistent with this patient's presentation or EKG.
4.7
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