MKSAP: 63-year-old man with pleuritic left-sided anterior chest pain

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 63-year-old man is evaluated for pleuritic left-sided anterior chest pain, which has persisted intermittently for 1 week. The pain lasts for hours at a time and is not provoked by exertion or relieved by rest but is worse when supine. He reports transient relief with acetaminophen and codeine and occasionally when leaning forward. He has had a low-grade fever for 3 days, without cough or chills. Medical history is significant for acute pericarditis 7 months ago. He was treated at that time with ibuprofen and had rapid resolution of his symptoms. His only current medications are acetaminophen and codeine.

On physical examination, temperature is 37.8 °C (100.0 °F), blood pressure is 132/78 mm Hg, pulse rate is 98/min, and respiration rate is 16/min. No jugular venous distention is noted. A two-component pericardial friction rub is heard over the left side of the sternum. Pulsus paradoxus of 6 mm Hg is noted. Lung auscultation reveals normal breath sounds with no wheezing. No pedal edema is present.

Electrocardiogram demonstrates sinus rhythm and no ST-segment shift.

Which of the following is the most appropriate management?

A: Azathioprine
B: Chest CT
C: Colchicine and aspirin
D: Pericardiectomy
E: Prednisone

MKSAP Answer and Critique

The correct answer is C: Colchicine and aspirin.

This patient most likely has recurrent pericarditis, and colchicine in combination with aspirin is the first-line treatment. He has pleuritic chest pain that is worse when supine and partially relieved by leaning forward and evidence of a pericardial friction rub. These findings are consistent with pericarditis. Lack of ST-segment elevation on electrocardiography does not exclude pericarditis. Seven months ago, he was diagnosed with acute pericarditis and treated with ibuprofen.

In patients with recurrent pericarditis who have not benefited from colchicine plus aspirin and who have not benefited from or cannot tolerate corticosteroid therapy, current guidelines support the use of alternative immunosuppressive therapy with azathioprine or cyclophosphamide. However, these third-line agents are not indicated in this patient who has yet to be treated with colchicine and aspirin.

Chest CT is useful for assessment of pericardial thickness when constrictive pericarditis is suspected on the basis of right heart failure (jugular venous distention, pedal edema, hepatic congestion). This patient has no such findings, and chest CT is not required.

In patients with acute or recurrent pericarditis, pericardiectomy does not prevent recurrent disease and is only indicated in patients who develop constrictive pericarditis.

Corticosteroids should generally be avoided for both acute and recurrent pericarditis because they increase the risk for recurrences. Prednisone is indicated in selected patients with recurrent pericarditis, such as those with pericarditis related to connective tissue disease and those with pericarditis refractory to colchicine and NSAIDs.

Key Point

  • Colchicine plus aspirin is the first-line treatment for recurrent pericarditis.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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