A 74-year-old man is being treated in the ICU for severe community-acquired pneumonia. In the evening, he has been reporting severe, sharp, substernal(胸骨后) chest pain with radiation of his symptoms. Vital signs are: blood pressure 132/68 mm Hg, heart rate 113 beats/min, respiratory rate 22 breaths/min, oxygen saturation 94% on 2 liters,and initial troponin T level 0.03 ng/dL. On physical examination, he is moderately distressed and sitting upright（端坐）. The rest of the examination is significant for flat neck veins, bibasilar rales（双肺底啰音） on lung examination, and distal, harsh, heart sounds. His ECG is shown below.
Which of the following is/are the most appropriate next step(s) in management?
A. Emergent percutaneous coronary intervention（急诊PCI）
B. Chest CT angiography and heparin infusion
C. Aggressive diuresis
D. Nonsteroidal anti-inflammatory therapy and reassurance
投票结果：
患者出现可能与肺炎相关的急性心包炎。急性心包炎的典型特征是急性胸痛伴放射至斜方肌，向前坐位、心包摩擦音和ECG描记显示弥漫性ST段抬高伴凹性上升和VR、V1导联ST段倒置。使用经胸超声心动图以评价是否存在可导致心包填塞的心包积液。80%～90%的急性心包炎病例，病因是特发性的。高达90%的急性特发性心包炎病例为自限性。推荐的初始治疗为非甾体抗炎药。也可采用与秋水仙碱联合治疗。最近的一项研究表明，联合治疗已被证明可降低持续性和复发性心包炎的发生率。
References:
- LeWinter MM. Acute pericarditis. N Engl J Med. 2014 Dec 18;371(25):2410-2416.
- Imazio M, Brucato A, Cemin R, et al; ICAP Investigators. A randomized trial of colchine for acute pericarditis. N Engl J Med. 2013 Oct 17;369(16):1522-1528.
- Spodick DH. Acute pericarditis: current concepts and practice. JAMA. 2003 Mar 5:289(9):1150-1153.
D
补充内容：
急性心包炎:表现出以下情况中两项时可 确诊:胸痛(典型的锐痛，座位前倾减轻，占 85%~90%);心包摩擦(不足 1/3);新的广泛 ST 段抬高或 PR 段下移(不超过 60%);心包积液(少量， 不超过 60%)。其他体征和症状可以根据病因或全 身性疾病。复发性心包炎被定义为首次心包炎后，经 4~6 周无症状间隔，心包炎复发。 至少符合下列条件之一者为高危:高热(>38°C)，亚急性病程无明确的急性发作、大量心包 积液(如舒张期无回声区> 20 mm)、心包填塞， NSAID 治疗无反应、心肌心包炎、免疫抑制、外伤 或口服抗凝药治疗。
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