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Tuesday, March 29, 2011

Acute viral pericarditis

A 26-year-old woman is evaluated for sharp left precordial chest pain preceded by 2 to 3 days of sore throat, diffuse myalgias, and malaise. The chest pain is nonradiating and is aggravated by deep breaths. She does not have cough, dyspnea, fever, dizziness, or palpitations. She has always been healthy and does not use illicit drugs. A member of her immediate family was recently diagnosed with infectious mononucleosis.

On physical examination, her temperature is 36.7 °C (98 °F), heart rate is 95/min, respiration rate is 24/min, and blood pressure is 110/60 mm Hg. No lymphadenopathy is present, and the jugular veins are not distended. Lungs are clear. Cardiac examination is notable for an intermittent systolic “squeaky” sound along the left sternal border.

An electrocardiogram shows diffuse 1 to 3 mm of ST elevation with an upwardly concave configuration. An echocardiogram shows no pericardial effusion.

Which of the following is the most appropriate initial treatment for this patient?
A Clopidogrel
B Heparin
C Indomethacin
D Prednisone

Key Point
The initial treatment for acute viral pericarditis is a high-dose nonsteroidal anti-inflammatory drug.

Answer and Critique (Correct Answer = C)

This patient's sharp, pleuritic chest pain preceded by 2 to 3 days of prodromal symptoms is characteristic of acute viral pericarditis. The pericardial friction rub is suggestive of acute pericarditis, and the presence of ST segments that are upwardly concave on electrocardiography further supports this diagnosis. The lack of a pericardial effusion on echocardiography does not exclude pericarditis, given that 40% of patients with pericarditis may not have this finding.

The recommended initial treatment for acute viral pericarditis is a high-dose nonsteroidal anti-inflammatory drug such as indomethacin or ibuprofen. Indomethacin is rapidly tapered after 5 to 7 days because of the potential for toxicity with long-term use. Aspirin may also be used, although the high doses required may cause gastrointestinal problems.

If severe chest pain remains after 2 to 3 days of nonsteroidal anti-inflammatory drug treatment in patients with acute pericarditis, a 7- to 10-day tapering course of corticosteroids should be considered. However, corticosteroids such as prednisone have associated toxicity and are not recommended as first-line agents in the treatment of uncomplicated acute pericarditis. Low-dose colchicine may be used as an alternative to corticosteroids.

An acute myocardial infarction should always be considered in the setting of chest pain with ST elevation on electrocardiography. However, this patient's young age, viral prodrome, quality of the pain, and friction rub point to a diagnosis of acute pericarditis, and anticoagulation in a patient with known acute pericarditis is contraindicated because of the potential for hemopericardium.

Clopidogrel has no benefit as an anti-inflammatory agent for the treatment of acute pericarditis and is not indicated.

1. Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med. 2004;351:2195-202. Erratum in: N Engl J Med. 2005;352:1163. [PMID: 15548780]

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