UWORLD |STEP 3

Educational objective: When pharmacologic therapy is needed, high-dose aspirin is the treatment of choice for symptomatic management of peri-infarction pericarditis. Other anti-inflammatory agents (eg, other nonsteroidal anti-inflammatory drugs, glucocorticoids) should be avoided as they may impair myocardial healing and increase the risk of ventricular septa! or free wall rupture.

Educational objective: Patients with peri-infarction pericarditis typically have pleuritic chest pain and a pericardia! friction rub <4 days following an acute myocardial infarction. The characteristic ECG changes of diffuse PR depression and ST elevation may also be present, but can be masked by ECG changes of recent myocardial infarction.

A 55-year-old man comes to the emergency department due to sudden onset of retrostemal chest pain. The pain began 10 hours ago and has been mostly constant, although he describes it as "being bad and then getting a little better." The patient has had no lightheadedness, syncope, or shortness of breath. ECG shows normal sinus rhythm with 2-mm ST-segment elevation in leads V2 to V5. He is taken emergently for cardiac catheterization and undergoes percutaneous coronary intervention with stent placement to the left anterior descending artery. After the procedure, the ST-segment changes improve and he has complete resolution of the chest pain. On the third night, just prior to discharge, he calls for the nurse due to the sudden onset of sharp, retrosternal chest pain. The patient first noticed the pain while turning around in bed; it worsens with deep breathing. Temperature is 37.8 C (100 F}, blood pressure is 134/80 mm Hg, heart rate is 108/min, and respirations are 22/min. Physical examination reveals regular heart sounds and clear lung fields. There is a scratchy sound heard during ventricular systole along the left sternal border. Abdominal palpation reveals no localized tenderness. ECG shows sinus tachycardia with Q waves and T-wave inversion in leads V2 to V5.

Educational objective: In patients with chest pain, the probability of clinically significant coronary artery disease (CAO) is based on chest pain characteristics, as well as patient age, sex, ECG findings, and CAO risk factors. Stress testing is the initial evaluation of choice in patients in whom there is reasonable suspicion of clinically significant, stable CAD.

A 62-year-old woman comes to the physician due to chest and epigastric discomfort over the last 6 months. She feels dull chest pressure while walking uphill at a fast pace. The patient says, "It is unusual. I feel this pressure only once in a while, even when doing the same thing. Sometimes it is worse when I walk fast after a heavy meal." She has a history of non ulcer dyspepsia and acid reflux disease and occasionally takes over-the-counter omeprazole. She has no shortness of breath, palpitations, lightheadedness, lower extremity swelling, or syncope. The patient is physically active and has a very hectic social lifestyle. Medical history includes "borderline" hypertension and anxiety disorder. She stopped taking antihypertensive medications 5 years ago. She is a lifetime nonsmoker. The patient does not use alcohol or illicit drugs. Her mother suffered a stroke at age 70 and her father died of prostate cancer. Blood pressure is 145/90 mm Hg and pulse is 80/min and regular. BM I is 29 kg/m2. No heart murmurs are heard on cardiac auscultation. There are no carotid bruits. The lungs are clear and the rest of the physical examination is unremarkable. Resting ECG shows normal sinus rhythm, normal voltage, and T-wave flattening in leads VS and V6. Laboratory studies show fasting blood glucose of 102 mg/dl and LDL cholesterol of 110 mg/dl.

Educational objective: Cardiogenic syncope due to ventricular tachycardia is suggested by the abrupt onset of syncope without prodrome and the presence of underlying structural heart disease. These patients are at risk of sudden cardiac death and require definitive evaluation and management.