Critical Care Medicine-Neurologic Disorders>>>>>Pericardial Diseases
Question 4#

A 44-year-old woman with a past medical history of asthma presents with acute onset chest pain of 2 hours duration. She reports being in her usual state of health until the morning, when she had acute onset of sharp substernal chest pain. The pain is sharp, does not radiate, and has an intensity of 8/10. It is worse when she leans forward. She does not have any associated shortness of breath, nausea, palpitations, or light-headedness. She denies any recent long car rides or airplane trips. Her son is recovering from an upper respiratory infection.

Vital signs include:

On physical examination, she has normal heart sounds without any murmurs, friction rub, or S3 or S4. There is no jugular venous distension. Laboratory findings are remarkable for a troponin T of 0.03 ng/dL (normal <0.01), d-dimer <500 ng/mL, leukocytosis to 14,000/ µL, creatinine 0.78 mg/dL, and CRP 3.5 mg/L. ECG shows nonspecific changes without evidence of active ischemia. Echocardiography shows a small pericardial effusion and normal biventricular function without wall motion abnormalities.

What is the best next step in the management of this patient?

a. Send home with close follow-up with primary care physician
b. Admit to hospital for heparin bolus and drip
c. Admit to hospital for observation, high-dose NSAIDs, and colchicine
d. Activate cardiac catheterization laboratory for coronary angiography immediately
e. Admit to hospital for exercise stress testing

Correct Answer is C

Comment:

Correct Answer: C

The patient presents with symptoms of positional chest pain after being exposed to a family member with a viral illness. She has evidence of mild myocardial injury with a very mildly elevated troponin, and echocardiogram shows no evidence of wall motion abnormalities but reveals a small pericardial effusion. The best unifying diagnosis here is myopericarditis, and the patient should be admitted to the hospital for observation and treatment with anti-inflammatory medications. The term myopericarditis or perimyocarditis refers to inflammatory injury that involves both the pericardium and myocardium. Myopericarditis indicates a primarily pericarditic syndrome, with symptoms of pericarditis (chest pain, often pleuritic and positional, nonspecific or widespread ECG changes, CRP elevations) along with elevation in cardiac injury biomarkers (troponin, CK-MB) without new global or focal left ventricular dysfunction. In contrast, perimyocarditis indicates a predominantly myocarditic syndrome with minor pericardial involvement and presents with new focal or diffuse left ventricular dysfunction along with some symptoms of pericarditis. Etiologies for both are similar and include cardiotropic viral illnesses, connective tissue diseases, inflammatory bowel diseases, radiation-induced myocardial injury, or drug-induced myocardial injury. The most common presentation of myopericarditis involves a preceding viral gastrointestinal or respiratory illness. 

Although myocarditis may require an endomyocardial biopsy for confirmation, most patients with myopericarditis have a benign prognosis and self-limited illness, and therefore biopsy is not necessary in the absence of ventricular dysfunction or heart failure. Mainstay for treatment is similar to pericarditis when ventricular function is preserved and consists of high-dose anti-inflammatory agents and exercise restriction.

References:

  1. Caforio AL, Pankuweit S, Arbustini E, et al. European Society of CardiologyWorking Group on Myocardial and Pericardial Diseases. Current state of knowledge on etiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013;34:2636-2648.
  2. Imazio M, Cooper LT. Management of myopericarditis. Expert Rev Cardiovasc Ther. 2013;11:193-201.
  3. Imazio M, Trinchero R. Myopericarditis: etiology, management, and prognosis. Int J Cardiol. 2008;127:17-26.