Cardiology>>>>>Pulmonary Hypertension And Pericardium
Question 13#

A 38-year-old patient with no prior medical history presents to the emergency room with 4 days of chest discomfort. He denies any recent trauma, fever, or use of anticoagulants. The pain is positional and the patient reports mild upper respiratory infection (URI) symptoms in the preceding week. Laboratory work is notable for elevated white blood cell count (neutrophil predominance) as well as elevated erythrocyte sedimentation rate (ESR)/high-sensitivity C-reactive protein (hsCRP); his troponin and other laboratory work is otherwise negative/normal. Electrocardiogram (ECG) is consistent with pericarditis. There is a low suspicion for acute coronary syndrome, and acute pericarditis is diagnosed with small effusion on the echocardiogram; the pain improves with analgesics.

Which of the following regimens is the most appropriate therapy for this patient to treat the acute episode and maintain remission?

a. Ibuprofen 600 TID for 2 weeks followed by taper and colchicine 0.5 mg BID for 3 months
b. Aspirin 325 daily and colchicine 0.5 mg BID for 2 weeks followed by taper
c. Ibuprofen 400 BID and colchicine 0.5 mg BID for 2 weeks followed by no taper
d. Prednisone 10 mg daily and ibuprofen 600 TID for 3 months followed by no taper

Correct Answer is A

Comment:

Ibuprofen 600 TID for 2 weeks followed by taper and colchicine 0.5 mg BID for 3 months. The patient presents with an initial attack of acute pericarditis without any high-risk features (small effusion, negative troponin, no fever/trauma, or anticoagulant use). The appropriate regimen in this case would be an NSAID (ibuprofen 600 to 800 mg TID or indomethacin 50 mg TID) for a course of 1 to 2 weeks with physician follow-up. In addition, the use of colchicine has been studied in two trials with improvement in symptom resolution and maintenance of remission at a dose of 0.5 mg (daily for <70 kg; BID for >70 kg) for a fixed period of 3 months. 

Aspirin and colchicine can be used together; however, the dosing is incorrect for Answer b (650 to 1,000 mg TID) and the colchicine should still be continued for 3 months. Prophylactic Proton-pump inhibitor (PPI) should be utilized during the high-dose NSAID use to prevent gastric ulcer. Answer c is incorrect (dosing of ibuprofen is incorrect). Answer d is incorrect since steroid therapy is only reserved for patients with NSAID or acetylsalicylic acid (ASA) contraindication or patients having relapsing pericarditis that is refractory to NSAID/ASA therapy.