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Question

Difficulty: EasyCardiovascular System

A 42-year-old man presents to the emergency department complaining of sharp, severe chest pain that began yesterday. He states that the pain is significantly worse when he breathes deeply or lies flat on his back, but it improves when he sits up and leans forward. He reports having had a mild upper respiratory infection with a sore throat one week ago. His temperature is 37.6°C (99.7°F), blood pressure is 120/80 mm Hg, heart rate is 95/min, respiratory rate is 16/min, and oxygen saturation is 99% on room air. Auscultation of the chest reveals a high-pitched, scratchy, three-component sound heard best at the left lower sternal border. An electrocardiogram (ECG) is obtained and shows diffuse, concave-upward ST-segment elevations and PR-segment depressions across multiple leads. Which of the following is the most appropriate initial treatment for this patient?

  1. Initiate oral ibuprofen and colchicineAnswer
  2. B
    Administer nebulized albuterol and oral glucocorticoids
  3. C
    Initiate empiric intravenous broad-spectrum antibiotics
  4. D
    Transfer immediately for primary percutaneous coronary intervention
  5. E
    Transport to the radiology suite for a computed tomography pulmonary angiogram

Answer

Initiate oral ibuprofen and colchicine
The patient's clinical presentation is textbook for acute pericarditis, most likely viral or idiopathic in nature given the preceding upper respiratory infection. The hallmark features include sharp, pleuritic chest pain that improves with leaning forward, a characteristic three-component pericardial friction rub, and widespread ST-segment elevations combined with PR-segment depressions on the electrocardiogram. The standard first-line treatment for acute viral or idiopathic pericarditis is dual therapy with a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen, and colchicine. This combination effectively reduces pericardial inflammation, relieves pain, and significantly lowers the risk of future pericarditis recurrences.

Step-by-Step Solution

1
Analyze the patient's clinical history and physical exam.
The patient has pleuritic, positional chest pain following a viral prodrome, accompanied by a pathognomonic pericardial friction rub.
Identifying these hallmark features is the first step in diagnosing acute pericarditis.
2
Evaluate the provided electrocardiogram findings.
The ECG shows diffuse ST-segment elevations and PR-segment depressions.
These ECG changes confirm the diagnosis of acute pericarditis and differentiate it from an acute myocardial infarction, which typically shows localized ST elevations.
3
Determine the standard first-line management for the diagnosed condition.
Treatment with a nonsteroidal anti-inflammatory drug (NSAID) and colchicine.
This combination targets the acute inflammation and significantly reduces the risk of recurrent pericarditis.

Key Concept

Acute viral or idiopathic pericarditis classically presents with pleuritic, positional chest pain, a pericardial friction rub, and diffuse ST elevations with PR depressions on ECG. First-line therapy consists of NSAIDs and colchicine.
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Topics

Cardiovascular System

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