1. Jennifer Zhou, MS4 Albert Einstein College of Medicine August 15, 2012 UT / MR# 02790949

2. Triage  UT: 25 yo male with chest pain  Afebrile, VSS  A&O x3  Pain scale: 0

3. History HPI  Pain onset this AM while doing clerical work  Sharp, stabbing 10/10 substernal pain radiating to back  Associated SOB, light-headedness, and diaphoresis  Denies n/v  Episode lasted 15 minutes  Prior episode of same pain two years ago for which he was hospitalized  Recurrence of pain in the past year (1-2 times per month)  Pt reports usual state of good health in recent weeks

4. History PMHx  Hospitalized two years ago for acute pericarditis PSHx  None Meds  None Allergies  NKMA FHx  DM – mother, 2 siblings SHx  Bank employee  Denies tobacco, EtOH, illicit drug use  Sexually active with one partner and uses no contraception

5. Physical Exam Vitals  BP 130/98  HR 55  T 98.9  RR 16  100% @RA Gen  NAD; sitting up in stretcher Neuro  Grossly intact Neck  Soft & supple; no JVD CV  RRR; S1/S2 noted with no additional sounds  Pain not reproducible with palpation Pulm  CTAB Abd  Soft, nontender, nondistended, normal bowel sounds

6. Deadly DDx for Chest Pain  PET MAC  Pulmonary embolism  Esophageal rupture  Tension pneumothorax  Myocardial infarction  Aortic dissection  Cardiac tamponade

7. DDx for UT  PET MAC  Angina pectoris  Esophagitis  GERD  Musculoskeletal pain  Pericarditis  PUD

8. Labs/Diagnostics CBC: 5.6> 16.4/46.8 >281 BMP: 139/4.3 100/28 17/1.3 83 Trop: <0.01 CPK: 266 CXR: WNL

9. EKG

10. Pericardium Normal  Parietal and visceral layers separated by 20- 50mL of plasma ultrafiltrate Pericarditis  Inflammation of pericardium with infiltration of PMNs  Fibrinous reaction with exudates, adhesions, effusions

12. Recurrent Pericarditis  15-30% recurrence after resolution of inciting event.  First recurrence usually within 18 months.  Generally not associated with severe complications  Low risk of myocardial systolic dysfunction  Low risk of effusion and tamponade  No reports of association with constrictive pericarditis

13. Predictors of Recurrence? No reliable predictors, but…. …individuals who did not respond to out- patient aspirin therapy had higher rates of recurrent pericarditis.

14. Treatment Options  Aspirin/NSAID for 1-2 weeks  Ibuprofen  Indomethacin  Aspirin  Colchicine for up to 6 months  Low dose to avoid GI side effects  +/- Glucocorticoid  Second-line  Low-moderate dosing with gradual tapering

16. Pericardiectomy 2004 ESC Guidelines  Class IIa recommendation  Indications: 1) More than one recurrence accompanied by cardiac tamponade 2) Recurrence principally manifested by persistent pain despite intensive medical treatment and evidence of glucocorticoid toxicity

18. Monitoring  ECG  CXR  Echocardiogram  ESR  CRP  WBC

19. Take Home Points 1) Recurrent pericarditis is common and not usually caused by reinfection. 2) Colchicine + aspirin/NSAID therapy recommended for prevention; avoid glucocorticoids if possible. 3) Encourage good f/u care.

20. References  Adler, Y. Recurrent pericarditis. In UpToDate, Basow, DS, UpToDate, Waltham MA, 2012.  Brucato A, Brambilla G, Moreo A, et al. Long-term outcomes in difficult-to-treat patients with recurrent pericarditis. Am J Cardiol 2006; 98:267.  Imazio M, Demichelis B, Parrini I, et al. Day-hospital treatment of acute pericarditis: a management program for outpatient therapy. J Am Coll Cardiol 2004; 43:1042.  Imazio M, Bobbio M, Cecchi E, et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation 2005; 112:2012.  Imazio M, Bobbio M, Cecchi E, et al. Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (COlchicine for REcurrent pericarditis) trial. Arch Intern Med 2005; 165:1987.