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Difficulty: EasyCardiovascular System

A 24-year-old man presents to the clinic with acute, sharp chest pain that started yesterday. The pain worsens when he takes a deep breath or lies supine, but significantly improves when he sits up and leans forward. He reports having had a mild upper respiratory tract infection one week ago. His temperature is 37.4°C (99.3°F), blood pressure is 120/78 mmHg, and pulse is 88/min. Cardiac auscultation reveals a scratchy, high-pitched extra sound at the left lower sternal border that is heard during both systole and diastole. An electrocardiogram demonstrates diffuse concave ST-segment elevations and PR-segment depressions in most leads. Which of the following is the most appropriate initial treatment for this patient's condition?

  1. Ibuprofen and colchicineAnswer
  2. B
    Intravenous furosemide
  3. C
    Inhaled albuterol and ipratropium
  4. D
    Broad-spectrum antibiotics
  5. E
    Systemic anticoagulation with heparin

Answer

The most appropriate initial treatment for this patient is ibuprofen and colchicine.
The clinical presentation of sharp, pleuritic chest pain that improves with sitting up and leaning forward, combined with a pericardial friction rub and diffuse ST-segment elevations, is classic for acute pericarditis. The most common etiologies are idiopathic and viral (often following an upper respiratory infection). The most appropriate initial pharmacotherapy for acute viral or idiopathic pericarditis is a combination of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or indomethacin, and colchicine. This combination provides symptomatic relief, reduces inflammation, and significantly lowers the rate of recurrence compared to using NSAIDs alone.

Step-by-Step Solution

1
Identify the primary clinical syndrome based on the patient's presentation and physical exam.
The patient has pleuritic chest pain relieved by leaning forward, preceded by a viral prodrome, and a scratchy friction rub, indicating acute pericarditis.
These are the textbook hallmark symptoms and physical signs of pericardial inflammation.
2
Confirm the diagnosis using the provided electrocardiogram findings.
The ECG shows diffuse ST-segment elevations and PR-segment depressions, which are pathognomonic for acute pericarditis.
ECG changes reflect widespread epicardial inflammation, distinguishing it from the localized changes seen in acute myocardial infarction.
3
Determine the most appropriate initial treatment for idiopathic or viral acute pericarditis.
The first-line pharmacotherapy is a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine.
NSAIDs relieve pain and active inflammation, while colchicine specifically targets neutrophils to reduce the risk of recurrent pericarditis.

Key Concept

Diagnosis and management of acute viral or idiopathic pericarditis
Estimated Time:1m 0s
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Topics

Cardiovascular System

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