What is the treatment and workup for pericarditis with elevated troponin (cardiac biomarker) in a 16-year-old male with no significant past medical history (PMH)?

From the Guidelines

For a 16-year-old male with pericarditis and elevated troponin without significant past medical history, the recommended approach involves both diagnostic workup and treatment, with a focus on reducing morbidity, mortality, and improving quality of life. The initial workup should include:

• ECG (looking for ST elevations, PR depression) 1
• Echocardiogram to assess for effusion
• Chest X-ray
• Laboratory tests including complete blood count, comprehensive metabolic panel, C-reactive protein, erythrocyte sedimentation rate, and cardiac biomarkers (troponin, CK-MB) 1 First-line treatment consists of:
• NSAIDs, typically ibuprofen 600-800mg three times daily or naproxen 500mg twice daily for 1-2 weeks, followed by a gradual taper over 2-4 weeks 1
• Colchicine should be added at 0.6mg twice daily for 3 months to reduce recurrence risk 1 The elevated troponin suggests myocardial involvement (myopericarditis), warranting closer monitoring and possible cardiology consultation 1. Activity restriction is essential until symptoms resolve and biomarkers normalize, typically 2-4 weeks. The patient should avoid competitive sports for at least 3 months. Hospitalization may be necessary for monitoring, especially with troponin elevation. Most cases are viral in etiology and self-limiting, but follow-up echocardiograms are recommended to ensure resolution and rule out complications like constrictive pericarditis 1.

Key considerations in management include:

• Identifying high-risk features, such as large pericardial effusion, cardiac tamponade, and failure to respond to NSAIDs 1
• Considering the use of corticosteroids as a second option in patients with contraindications and failure of aspirin or NSAIDs 1
• Restricting physical activity beyond ordinary sedentary life until resolution of symptoms and normalization of CRP 1

From the Research

Diagnosis and Treatment of Pericarditis with Elevated Troponin

• The diagnosis of pericarditis is based on clinical criteria, including chest pain, a pericardial rub, electrocardiographic changes, and pericardial effusion 2.
• Elevated troponin levels can be seen in myopericarditis, which is a pericarditic syndrome with some degree of myocardial involvement 3.
• The treatment of acute and recurrent pericarditis typically involves the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen, with the possible adjunct of colchicine 4, 5.
• Colchicine has been shown to be effective in reducing the risk of recurrent pericarditis, with a relative risk of 0.50 compared to standard treatment 4.
• Corticosteroids may be used as a second-line therapy for patients who do not respond to NSAIDs and colchicine, or who have contraindications to these medications 5, 6.
• The use of corticosteroids at low doses, with gradual tapering, may be a successful and safe treatment for acute and recurrent idiopathic pericarditis 6.

Workup for Pericarditis with Elevated Troponin

• The workup for pericarditis with elevated troponin should include an electrocardiogram (ECG) to evaluate for ST-T changes, as well as echocardiography to assess for pericardial effusion and left ventricular function 3, 2.
• Coronary angiography may be considered in patients with recurrent pericarditis or those who do not respond to standard treatment, to rule out coronary artery disease 3.
• Laboratory tests, including complete blood count, erythrocyte sedimentation rate, and C-reactive protein, may be helpful in evaluating the severity of inflammation and monitoring response to treatment 2.

Management of Pericarditis with Elevated Troponin in a 16-Year-Old Male

• The management of pericarditis with elevated troponin in a 16-year-old male should involve the use of NSAIDs, such as aspirin or ibuprofen, with the possible adjunct of colchicine 4, 5.
• The patient should be monitored closely for signs of recurrent pericarditis, and treated promptly if recurrences occur 4, 2.
• The use of corticosteroids should be considered if the patient does not respond to NSAIDs and colchicine, or if there are contraindications to these medications 5, 6.