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  #1  
Old 07-03-2011
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Heart Acute pericarditis with mild effusion--what's the next step?

In acute pericarditis due to viral infection by examination you suspect mild pleural effusion what next step ?


A- NSAID

B- Echocardiography


do we need to do echo to confirm effusion or just precede with treatment ?
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  #2  
Old 07-03-2011
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once diagnosis is made rule out complication of cardiac tamponade or to know its complicated or uncomplicated so i will go with echo
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Old 07-03-2011
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i am not sure but also why not give him treatment NSAID for pain then go for echo

actually i am not sure about this
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Old 07-03-2011
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The 2003 American College of Cardiology/American Heart Association/American Society of Echocardiography (ACC/AHA/ASE) guidelines for the clinical application of echocardiography stated that evidence and/or general agreement supported the use of echocardiography for the evaluation of all patients with suspected pericardial disease (from Uptodate)
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According to UpToDate: The diagnosis of acute pericarditis is usually suspected based on a history of characteristic pleuritic chest pain, and confirmed if a pericardial friction rub is present. Pericarditis should also be suspected in a patient with persistent fever and pericardial effusion or new unexplained cardiomegaly. Additional testing, which typically includes blood work, chest radiography, electrocardiography, and echocardiography, can support the diagnosis but is frequently normal or unrevealing. The electrocardiogram is usually the most helpful test in the evaluation of patients with suspected acute pericarditis. Echocardiography is often normal, but can be an essential part of the evaluation if there is evidence of an associated pericardial effusion and/or signs of cardiac tamponade.

In developed countries, most cases of acute pericarditis in immunocompetent patients are due to viral infection or are idiopathic. Because of the relatively benign course associated with the common causes of pericarditis, it not necessary to search for the etiology in all patients. As such, most patients are treated for a presumptive viral cause with nonsteroidal antiinflammatory drugs (NSAIDS) and colchicine.

--Based on this information, I would vote for NSAIDs.
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  #6  
Old 07-03-2011
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Quote:
Originally Posted by healer2b View Post
According to UpToDate: The diagnosis of acute pericarditis is usually suspected based on a history of characteristic pleuritic chest pain, and confirmed if a pericardial friction rub is present. Pericarditis should also be suspected in a patient with persistent fever and pericardial effusion or new unexplained cardiomegaly. Additional testing, which typically includes blood work, chest radiography, electrocardiography, and echocardiography, can support the diagnosis but is frequently normal or unrevealing. The electrocardiogram is usually the most helpful test in the evaluation of patients with suspected acute pericarditis. Echocardiography is often normal, but can be an essential part of the evaluation if there is evidence of an associated pericardial effusion and/or signs of cardiac tamponade.

In developed countries, most cases of acute pericarditis in immunocompetent patients are due to viral infection or are idiopathic. Because of the relatively benign course associated with the common causes of pericarditis, it not necessary to search for the etiology in all patients. As such, most patients are treated for a presumptive viral cause with nonsteroidal antiinflammatory drugs (NSAIDS) and colchicine.

--Based on this information, I would vote for NSAIDs.
There is no statement about not doing echo in pericarditis here! You are speaking about etiology ! not the pericarditis itself. The echo is recommended because if a small effusion is present it is highly diagnostic. And this is not my recommendation this is AHAs! The answer based on guidelines is Echo.
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Old 07-03-2011
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go with echo, always confirm the diagnosis first
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Old 07-04-2011
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i think healer2b is right the diagnosis is clear ( effusion from pericarditis )

treat now patient with NSAID and decrease his pain then after that do anything
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Old 07-04-2011
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As I'm a clinician, I would go - depending on clinical findings.

1) Patient's well and you're not suspectious of any serious pericardial disease, go with NSAID and see how it goes (I've done that a lot in my practice)

2) If not, proceed with more tests to identify underlying aetiology
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  #10  
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As now is 21th century, and recommendations are made based on vigorous research and evidence, i cannot just say i am clinician but do not conform to clinical guidelines. These recommendations are result of efforts of hundreds of researchers. Then why do we research? Just be heuristic and stick to our sensory organs!. I am sorry but i do not agree with you and i think the answer is not based on nothing!
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Class I1. Patients with suspected pericardial disease, including effusion, constriction, or effusive-constrictive process.2. Patients with suspected bleeding in the pericardial space, eg, trauma, perforation, etc.3. Follow-up study to evaluate recurrence of effusion or to diagnose early constriction. Repeat studies may be goal directed to answer a specific clinical question.4. Pericardial friction rub developing in acute myocardial infarction accompanied by symptoms such as persistent pain, hypotension, and nausea.
Class IIa1. Follow-up studies to detect early signs of tamponade in the presence of large or rapidly accumulating effusions. A goal-directed study may be appropriate.2. Echocardiographic guidance and monitoring of pericardiocentesis.
Class IIb1. Postsurgical pericardial disease, including postpericardiotomy syndrome, with potential for hemodynamic impairment.2. In the presence of a strong clinical suspicion and nondiagnostic TTE, TEE assessment of pericardial thickness to support a diagnosis of constrictive pericarditis.

Class III1. Routine follow-up of small pericardial effusion in clinically stable patients.2. Follow-up studies in patients with cancer or other terminal illness for whommanagement would not be influenced by echocardiographic findings.3. Assessment of pericardial thickness in patients without clinical evidence of constrictive pericarditis.4. Pericardial friction rub in early uncomplicated myocardial infarction or early postoperative period after cardiac surgery.
ACC/AHA classification
Class I:
Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.Class IIb: Usefulness/efficacy less well established by evidence/opinion.Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful and in some cases may be harmful.
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Old 07-04-2011
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Quote:
Originally Posted by kemoo View Post
In acute pericarditis due to viral infection by examination you suspect mild pleural effusion what next step ?


A- NSAID

B- Echocardiography


do we need to do echo to confirm effusion or just precede with treatment ?
Apparently the patient is clinically stable, so first NSAIDs and then Echo.
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  #13  
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Quote:
Originally Posted by kemoo View Post
In acute pericarditis due to viral infection by examination you suspect mild pleural effusion what next step ?


A- NSAID

B- Echocardiography


do we need to do echo to confirm effusion or just precede with treatment ?
Kemoo, I'm just checking--do you mean "pleural" effusion or pericardial?
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  #14  
Old 07-04-2011
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Quote:
Originally Posted by healer2b View Post
Kemoo, I'm just checking--do you mean "pleural" effusion or pericardial?
OMG!! Anybody was aware of that ....
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  #15  
Old 07-04-2011
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Just to be clear, I'm not saying that the echo should not be done. I agree that echo is recommended for all cases of suspected acute pericarditis. However, just as Kemoo and Sadalssud stated, given that the patient is not presenting with hemodynamic compromise suggestive of tamponade, I see no reason not to relieve the patient's pain (with NSAIDs) before completing the workup and doing the echo.

I have definitely been caught on questions where I focused on the next step in "diagnosis" as opposed to the next step in "management," which taught me how important it is to check the exact wording of the question before selecting and answer.
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  #16  
Old 07-05-2011
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ooooh sorry for mistake i mean mild pericardial effusion not pleural


sorry for this mistake :sorry::sorry::sorry:
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