Pericardial Disease — SAQ

Stem

A 28-year-old man presents to the emergency department with sharp, central chest pain that is worse on deep inspiration and when lying flat, and partially relieved by sitting forward. The pain radiates to the left trapezial ridge. He had a viral upper respiratory illness two weeks ago. On examination: temperature 37.8 deg C, BP 118/76, HR 102, SpO2 98 per cent on air, pulsus paradoxus 6 mmHg, JVP not raised. A high-pitched scratching three-component friction rub is heard at the left lower sternal border with the patient leaning forward in expiration. ECG shows diffuse concave ST elevation in leads I, II, aVL, aVF, V3-V6 with PR depression in the same leads and PR elevation in aVR; no reciprocal changes. Troponin is mildly raised at 0.08 ng/mL. ^[1][2]

Questions

a) Diagnosis and the criteria you used? (2 marks)

Acute idiopathic (likely viral) pericarditis. ESC 2015 criteria — at least 2 of 4: (1) typical pericarditic chest pain (sharp, pleuritic, positional, relieved by sitting forward); (2) pericardial friction rub (three-component, left sternal border, leaning forward in expiration); (3) ECG with new widespread ST elevation or PR depression (present here); (4) new or worsening pericardial effusion. The patient fulfils three of the four.^[1][2]

b) Three ECG features distinguishing this from acute STEMI? (3 marks)

1. ST morphology: diffuse concave ST elevation vs convex (tombstone) regional ST elevation of STEMI.
2. Reciprocal changes: absent in pericarditis; present in STEMI.
3. PR segment: diffuse PR depression in pericarditis (PR elevation in aVR); not a feature of STEMI. Additionally, evolution is over days to weeks through 4 stages in pericarditis versus hours with Q-wave evolution in STEMI; troponin in pericarditis is only mildly raised (myopericarditis) versus markedly in STEMI.^[1][2]

c) First-line drug treatment with agent, dose, route, duration? (3 marks)

• Aspirin 750 to 1000 mg PO every 8 hours (or ibuprofen 600 to 800 mg PO every 8 hours) for 1 to 2 weeks until pain and CRP settle, then taper.^[1]
• PLUS colchicine 0.5 mg PO twice daily (he is over 70 kg) for 3 months — halves recurrence (ICAP: incessant or recurrent pericarditis 16.7 vs 37.5 per cent, NNT 4).^[8]
• PLUS PPI gastroprotection (e.g. omeprazole 20 mg PO OD).
• Restricted physical activity until symptom-free and CRP normal.^[1]

d) Two reasons corticosteroids are NOT first-line for idiopathic pericarditis, and one situation where they ARE indicated? (2 marks)

Not first-line because: (1) prior corticosteroid use independently predicts further recurrence (odds ratio 2.89 in CORE) and promotes chronicity; (2) they are associated with more side-effects and drug-related readmissions.^[10] Indicated in pericarditis that is autoimmune (SLE, RA), uraemic, in pregnancy (NSAIDs contraindicated after 20 weeks), in true refractory disease, or where NSAID/colchicine are contraindicated — dose is prednisolone 0.2 to 0.5 mg/kg/day, taper slowly.^[1]

References4ShowHide

1. [1]Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases Eur Heart J, 2015.PMID 26320112
2. [2]Cremer PC, Klein AL, Imazio M Diagnosis, Risk Stratification, and Treatment of Pericarditis: A Review JAMA, 2024.PMID 39235771
3. [8]Imazio M, Brucato A, Cemin R, et al. A randomized trial of colchicine for acute pericarditis N Engl J Med, 2013.PMID 23992557
4. [10]Imazio M, Bobbio M, Cecchi E, et al. Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE trial Arch Intern Med, 2005.PMID 16186468