American College of Physicians: Internal Medicine — Doctors for Adults ®


The MKSAP Challenge

From the September ACP Observer, copyright 2003 by the American College of Physicians.

Clinical scenario

A 43-year-old man comes to the emergency room for evaluation of severe chest pain that awoke him from sleep. While the patient was seated, the pain gradually resolved after five minutes, but recurred several minutes later. The patient reports that he has had nasal congestion, nausea, fatigue and a low-grade fever for the past few days.

Physical examination shows a temperature of 38 C (100.4 F), heart rate of 104/min and recurrence of pain while lying in the left lateral decubitus position. A three-component pericardial friction rub is noted. Laboratory findings include a total leukocyte count of 11,000/L, an erythrocyte sedimentation rate of 55 mm/h, and a slightly elevated troponin level. Electrocardiogram shows diffuse ST-T-wave changes

Which of the following is the best course of treatment for this patient?

A. Metoprolol, 25 mg twice a day orally
B. Colchicine, 0.5 mg twice a day orally for 2 weeks
C. Prednisone, 25 mg/d orally for 2 weeks, followed by a taper
D. Indomethacin, 25 mg four times a day orally for 2 weeks
E. Reteplase, 10 U by intravenous bolus, repeated in 30 minutes

Answer: D

Educational objective: Recognize the clinical presentation of acute pericarditis.

This patient has the classic presentation of acute pericarditis associated with upper respiratory tract infection. This diagnosis is suggested by the clinical history of associated illness and positional exacerbation of pain and confirmed by the physical findings of pericardial friction rub, elevated erythrocyte sedimentation rate, and diffuse ST-segment elevation on the electrocardiogram. An echocardiogram is not needed for the diagnosis of pericarditis. Echocardiography is needed only if the patient has evidence of hemodynamic compromise. In this situation, pericardial effusion with tamponade must be excluded.

Nonsteroidal anti-inflammatory drugs are the treatment of choice for acute pericarditis. Adrenergic antagonists do not have a role in the direct management of acute pericarditis. Colchicine offers benefit in patients who have recurrent or relapsing pericarditis, but is not necessary in most cases of primary acute pericarditis. Corticosteroids may provide symptomatic relief, but are associated with recurrent pericarditis. Thrombolytic therapy can cause hemorrhagic pericardial effusion.

Reference. Oakley CM. Myocarditis, pericarditis and other pericardial diseases. Heart. 2000;84:449-54.

The above feature contains questions and answers excerpted from MKSAP 12 Update, an enhancement to the College's popular self-assessment program. For more information about MKSAP 12 Update, contact ACP Customer Service at 800-523-1546, ext. 2600, or 215-351-2600.


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