NU650 Unit 7 Chest Pain Workup, Myopericarditis Example

A Rising Troponin That Is Not a Heart Attack: A Chest Pain Workup for Myopericarditis in a 36-Year-Old Man Ten Days After a Cold

[Student Name]

Purdue University Global

NU650: AGACNP Introduction to Acute Care Management I

Unit 7 Chest Pain Workup

[Instructor Name]

[Date]

The patient is composite; troponin values, intervals and times are bracketed, and the assay's own reference limits are used.

Presentation

Mr. [A.] is a [36]-year-old man, a high school soccer coach with no medical history, who woke at [04:00] with sharp central chest pain. It is worse when he lies flat or breathes in, better when he sits forward, and does not change with exertion. [Ten] days ago he had a sore throat, cough and low fever that resolved on their own. He does not smoke, use cocaine or take any medication. On arrival his pulse is [104], blood pressure [128/78], respiratory rate [18], temperature [37.8] degrees Celsius and saturation [98] percent without oxygen. A scratchy, three-component sound is heard at the left lower sternal border with him leaning forward, consistent with a pericardial friction rub.

The 2021 AHA/ACC chest pain guideline advises describing chest pain as cardiac, possibly cardiac or noncardiac rather than typical or atypical (Gulati et al., 2021). His pain is possibly cardiac, but its positional and pleuritic features point toward the pericardium rather than the coronary arteries.

Diagnoses That Cannot Be Missed

Each life-threatening cause is screened with a named finding before any probability is estimated.

1. ST-elevation myocardial infarction. The ECG shows concave ST elevation in [eight] leads across more than one coronary territory, with PR depression in the limb and lateral leads and PR elevation in aVR, and no reciprocal ST depression except in aVR. That pattern fits pericarditis and does not fit a single occluded artery. A cardiologist reviewed the tracing at [05:10] and agreed that catheterization was not indicated.

2. Aortic dissection. Pain is not tearing or maximal at onset, pulses and pressures are equal in both arms, and the mediastinum is normal on radiograph.

3. Pulmonary embolism. His pain is pleuritic, but he has no risk factors, a normal saturation, no leg findings, and meets all eight PERC criteria, so no further testing is needed for embolism.

4. Pneumothorax. Both lungs sound the same, and no pleural line or collapsed lung appears on the film.

5. Cardiac tamponade. No hypotension, no jugular venous distension, and bedside echocardiography shows only a trivial effusion with no chamber collapse.

6. Esophageal rupture. No vomiting before the pain and no subcutaneous air.

Troponin and What It Shows

High-sensitivity troponin T, with an assay 99th percentile upper reference limit of [14] ng/L:

1. At [0] hours: [48] ng/L.

2. At [3] hours: [61] ng/L.

3. At [9] hours: [74] ng/L.

The values are above the reference limit and rising, which shows myocardial injury. They do not by themselves show myocardial infarction. Infarction requires injury in a clinical setting of ischemia, and nothing here suggests ischemia: the pain is positional, the ECG pattern is diffuse, and the heart's walls move normally on echocardiography. A troponin answers whether heart muscle is injured; it cannot answer why, and the why is what decides the treatment.

C-reactive protein is [58] mg/L. On formal echocardiography his ejection fraction is [60] percent, and every wall segment contracts normally.

Diagnosis

Acute pericarditis is diagnosed when at least two of four criteria are present: pericarditic chest pain, a friction rub, new widespread ST elevation or PR depression, and a new or worsening pericardial effusion (Adler et al., 2015). Mr. [A.] has all four. His raised troponin with preserved ventricular function indicates myocardial involvement, which the ESC guideline calls myopericarditis. The viral illness [ten] days earlier makes a viral cause most likely, and no further search for a cause is needed at this stage in a young man with a typical course.

The main alternative that would change management is myocarditis with reduced function, which is excluded by his normal ejection fraction. Coronary disease is very unlikely in a [36]-year-old nonsmoker with this presentation; if chest pain with exertion developed later, or if cardiac magnetic resonance showed an ischemic pattern, that judgment would be revisited.

Disposition and Treatment

Uncomplicated acute pericarditis can often be treated at home. Mr. [A.] is admitted because of his myocardial involvement. The ESC guideline recommends hospital admission for diagnosis and monitoring when the myocardium is involved, with rest and avoidance of physical activity beyond ordinary daily life (Adler et al., 2015). He will be admitted to a telemetry bed for [24 to 48] hours to watch for arrhythmia and to repeat the troponin until it falls.

Treatment is ibuprofen [600 mg] every [eight] hours with a proton pump inhibitor for gastric protection, tapered once pain and C-reactive protein settle. Colchicine added to conventional anti-inflammatory therapy reduced incessant or recurrent pericarditis from 37.5 to 16.7 percent in the ICAP trial (Imazio et al., 2013b), and it will be started after discussion with cardiology, since that evidence comes from pericarditis rather than from patients with myocardial involvement. Cardiac magnetic resonance is planned as an outpatient to confirm and measure the myocardial involvement.

The most important instruction is about exercise. As a coach who plays with his team, he will be told to stop competitive and strenuous activity for at least [three to six] months and to return only after a cardiology review with repeat testing.

What Would Change the Plan

Three findings during the admission would reopen the diagnosis. A troponin that keeps climbing after [24] hours, rather than peaking and falling, would raise concern for a more extensive myocarditis and call for earlier cardiac magnetic resonance. A new arrhythmia on telemetry, particularly ventricular ectopy in runs, would prompt cardiology review before discharge. And a fall in ejection fraction on repeat imaging would change the label from myopericarditis to perimyocarditis, with a different treatment plan and a longer period of monitoring. None of these is expected in a young man with a typical course, but naming them in advance lets the overnight team act on them without a new debate about the diagnosis.

Prognosis and Follow-Up

In a multicenter cohort of patients with pericarditis with or without myocardial involvement, left ventricular function normalized in more than 90 percent of those with myocardial involvement, no deaths were recorded, and troponin elevation was not a marker of poor outcome in this setting (Imazio et al., 2013a). He will be told that his outlook is good, which matters for a young man who has just been told his heart muscle is inflamed. Follow-up with cardiology is booked at [two] weeks, with a repeat C-reactive protein and ECG.

References

Adler, Y., Charron, P., Imazio, M., Badano, L., Barón-Esquivias, G., Bogaert, J., Brucato, A., Gueret, P., Klingel, K., Lionis, C., Maisch, B., Mayosi, B., Pavie, A., Ristić, A. D., Sabaté Tenas, M., Seferovic, P., Swedberg, K., & Tomkowski, W. (2015). 2015 ESC guidelines for the diagnosis and management of pericardial diseases. European Heart Journal, 36(42), 2921-2964. https://doi.org/10.1093/eurheartj/ehv318

Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., Bhatt, D. L., Birtcher, K. K., Blankstein, R., Boyd, J., Bullock-Palmer, R. P., Conejo, T., Diercks, D. B., Gentile, F., Greenwood, J. P., Hess, E. P., Hollenberg, S. M., Jaber, W. A., Jneid, H., Joglar, J. A., Morrow, D. A., . . . Shaw, L. J. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. Circulation, 144(22), e368-e454. https://doi.org/10.1161/CIR.0000000000001029

Imazio, M., Brucato, A., Barbieri, A., Ferroni, F., Maestroni, S., Ligabue, G., Chinaglia, A., Cumetti, D., Della Casa, G., Bonomi, F., Mantovani, F., Di Corato, P., Lugli, R., Faletti, R., Leuzzi, S., Bonamini, R., Modena, M. G., & Belli, R. (2013a). Good prognosis for pericarditis with and without myocardial involvement: Results from a multicenter, prospective cohort study. Circulation, 128(1), 42-49. https://doi.org/10.1161/CIRCULATIONAHA.113.001531

Imazio, M., Brucato, A., Cemin, R., Ferrua, S., Maggiolini, S., Beqaraj, F., Demarie, D., Forno, D., Ferro, S., Maestroni, S., Belli, R., Trinchero, R., Spodick, D. H., & Adler, Y. (2013b). A randomized trial of colchicine for acute pericarditis. New England Journal of Medicine, 369(16), 1522-1528. https://doi.org/10.1056/NEJMoa1208536