Athlete's Heart: More Than Just Muscle

Ms. S. is a 46-year-old female who initially presents to her local Emergency Department with 1 week of chest pain. She describes the pain as dull, achy, and substernal that is made worse with inspiration. The pain limits her ability to lie flat. She denies any preceding infectious symptoms, history of myocardial infarction (MI), new medications, or open-heart surgery. She is admitted and diagnosed with acute pericarditis.

  • PMH: Gastroesophageal reflux disease (GERD), ascending aorta enlargement, esophageal yeast infection
  • PsHx: 5 right and 4 Left arthroscopic knee surgeries
  • Social Hx: Women's basketball coach. Never smoker.
  • Family Hx: Father MI age 50s; brother s/p DES age 50s; both maternal grandparents hx of MI, unknown age.
  • Medications: Esomeprazole 40 mg twice daily, domperidone 10 mg three times daily (TID), ranitidine HCl 300 mg daily, NORCO7.5-325 mg per q4 PRN
  • Allergies: No known drug allergies
  • Labwork: Normal CMP, CBC, d-dimer, negative ANA, and UsCRP 4.0mg/L
  • Electrocardiogram (ECG): non-specific T wave changes
  • Chest x-ray (CXR): unremarkable
  • Echocardiogram: small pericardial effusion
  • Physical exam: vital signs normal, wt. 62kg. Normal S1, S2, no S3 or S4. No pericardial friction rub or pericardial knock. JVP not noticeably elevated. Lower extremities warm and non-edematous

She is treated with ibuprofen 800 mg TID and colchicine 0.6 mg daily. This provides relief and she soon returns to coaching basketball. Unfortunately, after 1 month she returns with similar complaints especially after a long day of running up and down the court. Repeat UsCRP 56 mg/L. Cardiac magnetic resonance imaging (MRI) is obtained and reveals moderate late gadolinium enhancement (LGE) of the pericardium. She is started on prednisone 20 mg daily and restarted on ibuprofen 800 mg TID and colchicine 0.6 mg daily. The patient is maintained on this regimen for 3 months, but symptoms persist. Repeat cardiac MRI notable for persistent moderate LGE of the pericardium. Work up for etiologies was unremarkable and she was diagnosed with idiopathic recurrent pericarditis.

Figure 1
Image 1: Demonstrates initial cardiac MRI with LGE of the pericardium in the setting of active pericarditis during anti-inflammatory therapy (red arrows indicating LGE enhancement of the pericardium indicating inflammation). 2. Cardiac MRI after ongoing exercise during medical therapy with worsening LGE enhancement. 3. Cardiac MRI after restriction of exercise without changes in medical therapy and improved LGE. Adapted from Shah, NP, Verma BR, Chandra AK, et al. Exercise is good for the heart but not for the inflamed pericardium? JACC Cardiovasc Imaging 2019;12:1880-81.

What is the next best step in management of her symptoms?

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