A 64-year-old man comes to the emergency department with sharp, left-sided chest pain for the last 24 hours. The pain is worsened by deep breathing and relieved with leaning forward. He also complains of decreased appetite, fatigue, and occasional nausea over the last several weeks. He suffered an acute non-ST-elevation myocardial infarction 1 year ago and had stent placement in the right coronary artery. His other medical problems include type 2 diabetes mellitus complicated by retinopathy and peripheral neuropathy, hypertension, hyperlipidemia, hypothyroidism, and chronic kidney disease. His temperature is 36.1° C (97° F), blood pressure is 142/86 mm Hg, pulse is 98/min, and respirations are 16/min. A friction rub is heard at the left lower sternal border. Electrocardiogram shows normal sinus rhythm with asymmetric T-wave inversion in leads V5 and V6. Laboratory results are as follows: Which of the following is the most appropriate therapy for this patient's chest pain?

Question

A 64-year-old man comes to the emergency department with sharp, left-sided chest pain for the last 24 hours.  The pain is worsened by deep breathing and relieved with leaning forward.  He also complains of decreased appetite, fatigue, and occasional nausea over the last several weeks.  He suffered an acute non-ST-elevation myocardial infarction 1 year ago and had stent placement in the right coronary artery.  His other medical problems include type 2 diabetes mellitus complicated by retinopathy and peripheral neuropathy, hypertension, hyperlipidemia, hypothyroidism, and chronic kidney disease.  His temperature is 36.1° C (97° F), blood pressure is 142/86 mm Hg, pulse is 98/min, and respirations are 16/min.  A friction rub is heard at the left lower sternal border.  Electrocardiogram shows normal sinus rhythm with asymmetric T-wave inversion in leads V5 and V6.  Laboratory results are as follows:  Which of the following is the most appropriate therapy for this patient's chest pain?

Quizplus · Accepted Answer

11ec25c8_d340_3553_bc81_c9356b6c3103_MD0003_00 This patient's presentation (sharp and pleuritic chest pain, pericardial friction rub, uremia) is consistent with uremic pericarditis (UP). UP occurs in 6%-10% of renal failure patients, typically in those with blood urea nitrogen (BUN) levels >60 mg/dL. However, the degree of pericarditis does not always correlate with the degree of serum BUN or creatinine elevation. UP does not usually present with the classic electrocardiogram findings of pericarditis (eg, diffuse ST-segment elevations) as the inflammatory cells do not penetrate the myocardium. Dialysis is the most effective treatment for UP and can resolve symptoms and decrease the size of any pericardial effusion. Systemic anticoagulation (eg, heparin) can cause hemorrhage into the pericardial space and should be avoided during hemodialysis. Although this patient has a history of myocardial infarction, post-myocardial pericarditis (Dressler's syndrome) usually occurs within 1-6 weeks after myocardial infarction. (Choices A and D) Nonsteroidal anti-inflammatory drugs (eg, aspirin, naproxen, ibuprofen, indomethacin) and/or colchicine are generally used as first-line agents for most patients with idiopathic or acute viral pericarditis. They are normally used in UP patients not responding to dialysis. (Choice C) Heparin infusion would be appropriate in patients presenting with acute coronary syndrome. This patient's chest pain is more consistent with pericarditis, and his mild troponin elevation is likely due to the underlying renal failure. Moreover, the use of heparin in UP can lead to hemorrhage in the pericardial space and should be avoided. (Choice E) Pericardiocentesis should be performed in patients with symptoms or signs suggesting cardiac tamponade (eg, hypotension, distended neck veins, pulsus paradoxus). It is also occasionally performed for diagnostic reasons when the etiology of pericardial effusion is not clear. (Choice F) Glucocorticoids (eg, prednisone) can be used in patients with inadequate response to initial dialysis. They have a low success rate and have been associated with a higher risk of recurrence. Educational objective: Uremic pericarditis (UP) occurs in 6%-10% of renal failure patients, typically those with blood urea nitrogen levels >60 mg/dL. Most UP patients do not present with the classic electrocardiogram changes of pericarditis (eg, diffuse ST-segment elevations). Hemodialysis leads to rapid resolution of chest pain and reduces the size of any associated pericardial effusion. References: Pericardial involvement in end-stage renal disease. (http://www.ncbi.nlm.nih.gov/pubmed/12695728) Pericardial disease in renal patients. (http://www.ncbi.nlm.nih.gov/pubmed/11172559)

A 64-Year-Old Man Comes to the Emergency Department with Sharp