Cardiology Case Challenge: Worsening Chest Pain After a Respiratory Infection in a Man With Hypertension

Abhimanyu Beri, MD; Fadi Abu-Yasin, MD


March 24, 2022

The treatment of acute pericarditis not complicated by cardiac tamponade depends on whether a primary cause is identified or highly suspected. Therapy for patients with idiopathic pericarditis is aimed at the relief of chest pain and inflammation. Treatment has not been shown to prevent tamponade or long-term complications, such as constrictive pericarditis or recurrent pericarditis.

Although nonsteroidal anti-inflammatory drugs are the traditional mainstay of therapy, data suggest that colchicine, administered at a dosage of 0.6 mg twice daily for 90 days, is more likely to prevent recurrent idiopathic pericarditis. However, aspirin (2-4 g/day), indomethacin (75-225 mg/day), or ibuprofen (1600-3200 mg/day) are still often prescribed. Colchicine is also preferred for patients who have recurrent pericarditis.

Typically, symptoms improve within days of initiation of anti-inflammatory therapy. If chest pain persists after 2 weeks of treatment, a different agent or combination therapy should be considered.

If a patient continues to have chest pain despite combination therapy, glucocorticoids should be considered. Some data suggest that the use of steroids is associated with a higher risk for later recurrence. Patients with a relapse of pericarditis after a short-term course of low-dose glucocorticoid therapy often obtain symptomatic relief when higher-dose prednisone therapy (1-1.5 mg/kg of body weight daily) is administered for 4 weeks.[2,3,5]

Therapy for secondary pericarditis is targeted at the primary cause. In cases of HIV-associated pericarditis, appropriate antibiotics or antivirals for targeting the infection should be used. For patients with autoimmune conditions, steroids or other immunomodulators are usually appropriate in consultation with the primary care clinician.

A diagnosis of acute pericarditis should be reserved for patients with an audible pericardial friction rub or chest pain with typical ECG findings, most notably widespread ST-segment elevation. Indicators of a poor prognosis include a temperature > 100.4°F (38°C), a subacute onset (ie, symptoms developing over several weeks), an immunosuppressed state, pericarditis associated with trauma, a history of oral anticoagulation therapy, myopericarditis (pericarditis with clinical or serologic evidence of myocardial involvement), a large pericardial effusion (an echo-free space > 20 mm in width) or cardiac tamponade.[2]

The patient in this case had multiple coronary artery disease risk factors but presented with a history that is typical of acute pericarditis. Although the initial physical examination was normal, reexamination several hours later revealed the presence of a friction rub. His initial ECG was ambiguous; however, the next morning, a repeat ECG showed more pronounced changes (Figure 2).

Figure 2.

His creatine kinase level gradually came down, and his troponin remained normal. Given these findings, a two-dimensional echocardiogram was ordered and his ESR and CRP were checked, both of which had normal results. His rheumatoid factor and antinuclear antibody examinations were normal as well.

The patient was started on colchicine at 2 mg on day 1, which was then reduced to 0.5 mg twice daily for 90 days. His symptoms resolved within 24 hours. He was discharged from the hospital. On an outpatient cardiac stress test, no evidence of ischemia was noted.


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