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.
Bibliography

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]

Arterial ischemia

A 72-year-old man is evaluated in the office for bilateral leg pain and cramping after walking briskly up an incline. The pain is in the distal thigh and calf and is worse on the right side. He has no pain when walking downhill. The patient has a 100-pack-year smoking history, type 2 diabetes mellitus, hypertension, and heart failure. His medications are captopril, furosemide, atenolol, atorvastatin, metformin, and aspirin.

On physical examination, the blood pressure is 146/68 mm Hg and heart rate 82/min and regular. The lungs are clear. Cardiac examination reveals an S4. There is a right femoral artery bruit with absent pulses and mild dependent rubor. Ankle-brachial index is 0.8.

Which of the following is the most likely cause of this patient's symptoms?
A Arterial ischemia
B Osteoarthritis
C Peripheral neuropathy
D Right popliteal venous thrombosis
E Spinal stenosis

Key Points

* Most patients with peripheral vascular disease have an ankle-brachial index (ABI) <0.9, and those with severe disease (rest ischemia) have an ABI <0.4.
* An ABI >1.3 indicates vascular calcification.

Answer and Critique (Correct Answer = A)

The patient's history of exercise-induced leg pain, its relief with rest or walking downhill, vascular bruit and absent pulses on physical examination, dependent rubor, and several major risk factors for atherosclerotic artery disease all point to arterial ischemia as the cause of his symptoms. Determination of the ankle-brachial index (ABI) is a common initial test in the evaluation for peripheral vascular disease. With a Doppler probe, the ABI is measured as the ratio of the highest right/left dorsalis pedis/posterior tibial artery systolic pressure divided by the highest right/left brachial artery systolic pressure. A normal ABI is 1.0 to 1.3. Most patients with peripheral vascular disease have an ABI <0.9, and those with severe disease (rest ischemia) have an ABI of <0.4. An ABI >1.3 suggests a calcified, noncompressible vessel, most commonly seen in patients with long-standing diabetes mellitus and hypertension.

Peripheral neuropathy would be unlikely to present as pain with exercise. Spinal stenosis commonly presents as pain with standing and after walking a variable distance, most prominently with spinal extension, and is usually relieved by flexing forward, sitting, or lying down. Like spinal stenosis, osteoarthritis may cause pain on walking but is usually independent of grade; neither condition can account for the patient's other findings including bruit, diminished pulses, dependent rubor, and abnormal ABI. Popliteal venous thrombosis may present with localized pain and erythema, but the pain would not be exertional and cannot account for bilateral pain or the physical examination findings.

Bibliography
1. Khan NA, Rahim SA, Anand SS, Simel DL, Panju A. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA. 2006;295:536-46