58-year-old with pleuritic chest pain and friction rub
A 58-year-old woman with rheumatoid arthritis presents with 3 days of sharp chest pain that worsens with inspiration and lying supine and improves when she leans forward. She had a viral upper respiratory illness 2 weeks ago. Temperature is 37.8 C, blood pressure 126/74 mm Hg, pulse 102/min. A scratchy sound is heard along the left sternal border. ECG shows diffuse ST-segment elevation with PR-segment depression. Troponin is normal. Echocardiogram shows a moderate circumferential pericardial effusion without right atrial or right ventricular collapse. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
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B
Explanation
Clinical Pearl:
Acute pericarditis is treated first-line with an NSAID plus colchicine when there is no hemodynamic compromise or another specific indication for drainage. A pericardial effusion alone does not mandate pericardiocentesis unless tamponade, purulence, or diagnostic uncertainty is present.
Explanation:
This patient has acute pericarditis, supported by pleuritic positional chest pain, a pericardial friction rub, and diffuse ST elevation with PR depression. Current guideline-based management for uncomplicated acute pericarditis is an NSAID, such as ibuprofen, together with colchicine to improve symptom control and reduce recurrence. Urgent pericardiocentesis is not indicated because the echocardiogram shows no chamber collapse and she has no hypotension or other signs of tamponade. Therapeutic anticoagulation would not treat the syndrome and can worsen hemorrhagic pericardial effusion in the wrong setting. Immediate coronary angiography is not the best step because the ECG pattern and normal troponin favor pericarditis rather than acute coronary occlusion. High-dose glucocorticoids are usually reserved for selected cases such as refractory symptoms, contraindication to NSAIDs, or a defined autoimmune indication, because routine first-line use increases recurrence risk.
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