Management of Suspected Rheumatologic Disease with Cardiopulmonary Involvement

Immediate Life-Threatening Conditions to Exclude

The American College of Cardiology recommends obtaining an ECG within 10 minutes of ED arrival to assess for signs of right heart strain, and measuring cardiac troponin immediately upon presentation, in patients with suspected pulmonary embolism, with a high risk of cardiac complications 1, 2, 3
The American College of Radiology suggests using validated clinical decision rules, such as the Wells score or Geneva score, to determine pretest probability of pulmonary embolism, and obtaining D-dimer with age-adjusted cutoffs if low-to-intermediate probability 4, 5
The American College of Cardiology recommends that patients with acute coronary syndrome should have an ECG obtained and reviewed within 10 minutes of arrival, and cardiac troponin should be measured as soon as possible 1, 2, 3
The European Heart Journal recommends administering oxygen to maintain SpO2 >90%, establishing IV access and initiating crystalloid hydration, and considering aspirin 162-325 mg if ACS suspected and no contraindications, in pre-hospital/initial ED management 8, 1

The American College of Rheumatology suggests that small joint swelling with limited finger mobility is pathognomonic for inflammatory arthritis, most commonly rheumatoid arthritis, and pleuritic chest pain may indicate pleural effusion or pleuritis, both extra-articular manifestations of RA 6, 5

The American Heart Association recommends transporting urgently to ED by EMS if any of the following are present: age >52 years with dyspnea and pleuritic chest pain, bilateral crackles suggesting pulmonary edema or interstitial process, inability to perform activities of daily living, or any ECG abnormalities suggestive of ischemia or pericarditis 1, 2, 6

The American College of Cardiology recommends initiating anticoagulation with therapeutic-dose heparin or low-molecular-weight heparin, and transitioning to warfarin for 6-12 months, if pulmonary embolism is confirmed, and using NSAIDs plus colchicine for pericarditis, with consideration of steroids for refractory cases 7, 5