Clinical Case 051: Cardiac conundrum
This week’s case is “chest pain” in a relatively young man.
I am going to make it tricky by giving you info bit by bit – see if you smart buggers can work it out.
Step 1 – here is the initial ECG. 2 hours of central chest pain. What is happening? what are you going to do?
Does he meet criteria for thrombolysis?
OK – so you all seem to agree he has pericarditis on the ECG. And the history was convincing – 23 yo, pleuritic left chest pain, radiating to the left arm. He had a story of an acute “strept throat” and was just finished a week of oral penicillin. BUT – the initial tropT was 0.88, and in the morning it was up to 16! So he clearly has more than a simple pericarditis.
Just to be sure, late at night I did a bedside ECHO to check if he had anything suspicious. This showed a small pericardial effusion and no “eyeball” evidence of regional (inferior) wall motion abnormality (for what it is worth with me – an ECHO gumby looking with my eyeballs!)
So lets say he has a myopericarditis. Let us now look at the treatment. How do you manage this? And if you are super-smart – are there any other causes to consider other than “viral”?
If you are unaware of Dr Smith’s ECG blog then check out the section on pericarditis here – lots of pearls for telling MI from pericaritis.
Let me know on he comments.
I assume History and exam are unremarkable..as well as lab results.
Looks suspicious for pericarditis – widespread concave STE without reciprocal changes. No PR depression though.
I’d take further history to clarify – was it pleuritic, better on sitting forwards, recent URTI/gastro etc. Examine for a rub but I’ve never heard this outside of post-op cardiac patients.
Would do a trop to see if myopericarditis (or ischaemia if Hx pointed that way), while waiting for that give him some aspirin to cover that base, plus a full dose of an NSAID to treat the pain + paracetamol +/- some opiates depending on response/severity.
A rpt ECG in an hour or so might be more obvious, pericarditis often takes time to become obvious.
ECG aspect evokes pericarditis, probably “dry” because lot of liquid in the pericardium would have shown small complex
for 2 hours even if young patients can have acute coronary syndrome, pericarditis is more credible
no thrombolysis. symptomatic treatment, aspirin bolus if no contraindications while waiting for biology to see inflammation, leucocytes, cardiac biomarkers with Troponin and chest x ray
I’m also leaning towards pericarditis
However, in the true spirit of medicine I’d like to back up a little from the ECGand ask some Qs (history and exam for us old timers)
Need more details on chest pain – site, onset, character, radiaiton, exacerbating/alleviating factors, other symptoms..
Need more on him – fit chap? Sig PMHx? Drugs? Allergies? FHx yada yada
And on exam – cardio and resp Sx exams? Any epigastric pain? Old ECGs?
Then Rx as per the above
I am spoiled locally – always have the option of ‘phone a friend’ by the truly excellent State-wide ICCnet service – basiclaly can either fax and ECG or ring for advice and get a consultant cardiologist on the ine 24 hrs a day. GREAT servive for us rural docs here in southern Oz.
I guess you need more information, so I would agree with Andrew and Tim, and give him Aspirin in the mean time.
Rheumatic fever related carditis
This is a salient coroners case of this condition. take note rural docs…and others
Was there a cath done?
Got a chuckle out of the cath question.
I work about 2000 km from the closest cath lab! So no cath.
This is the reality of remote practice – you rely on tests that the rest of the world would not.
Apologies for leaving you all hanging on this one. Will come up with a conclusion after some research and pro-input.
I understand the lack of MRI (which would be really nice) and cath but it would be helpful with a repeat echo (or several depending on anxiety level) and BNP. Even a myocarditis can get pretty sick and it’s always nice to know a little bit before they crash. But the precise diagnosis is beyond me at this stage
High-dose pulse-steroids are an option I think, but I believe unproven, to reduce myocardial damage. NSAIDS should continue, plus a PPI!
Apart from viruses I’d be thinking about lupus, rheumatic carditis as Minh mentioned, and drug-related. In Central/South America Chagas disease. There’s probably a few other weird infectious causes I don’t know about – how about a consult?
Good thoughts – I will need to look into the steroids vs. NSAIDs question.
On further history the next day the chap gave a prey good description of a chorea-like involuntary movement which he didn’t seek help for a few months prior!
Does that seal the diagnosis for us? 2 major Jones criteria I think