A 64-year-old man comes to the emergency department due to chest pain. Four weeks ago, the patient was hospitalized for an acute myocardial infarction, and he is afraid the heart attack is recurring. He localizes the pain to the middle of his chest; he can take only shallow breaths because deep breaths make the pain worse. Leaning forward in his chair relieves the pain somewhat. The patient also has associated neck pain and general malaise but has not had any shortness of breath, palpitations, syncope, or cough. Temperature is 36.7 C (98 F), blood pressure is 135/84 mm Hg, and pulse is 90/min. ECG reveals ST-segment elevations in all limb and precordial leads except V1 and aVR, which demonstrate ST-segment depressions. Which of the following is the best next step in management of this patient?
Post–cardiac injury syndrome | |
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NSAID = nonsteroidal anti-inflammatory drug. | |
The patient's chest pain characteristics (eg, worse with deep inspiration, relieved with leaning forward) and ECG findings (ie, diffuse ST-segment elevations with reciprocal depressions in leads V1 and aVR) are consistent with acute pericarditis. Given his recent myocardial infarction (MI), he most likely has post–cardiac injury syndrome (PCIS), a pericarditis that can occur several weeks to months after cardiac injury. When PCIS occurs following MI specifically, it may be referred to as Dressler syndrome.
PCIS represents an immunologic response to damaged mesothelial pericardial cells and blood in the pericardial space. In addition to chest pain, patients often have malaise and sometimes fever. Inflammatory markers, including erythrocyte sedimentation rate and C-reactive protein, are typically elevated. Appropriate therapy consists of a nonsteroidal anti-inflammatory drug (NSAID) in the form of high-dose aspirin (eg, 975 mg 3 times a day) or a nonaspirin NSAID (eg, ibuprofen 800 mg 3 times a day); aspirin usually is preferred because post-MI patients are already taking it in low doses for the antiplatelet effect. Colchicine may be added for enhanced anti-inflammatory effect. Corticosteroids can be used for refractory pain or when NSAIDs are contraindicated, but they are less effective overall.
In contrast to PCIS, peri-infarction pericarditis results from local myopericardial inflammation and usually develops within 4 days of MI. Treatment with NSAIDs is usually avoided due to a possible increased risk of myocardial rupture in the early post-MI period.
(Choices A and B) Anticoagulation with heparin (but not warfarin, which is typically avoided in the acute setting) would be appropriate if this patient were having a recurrent MI, but his chest pain characteristics and ECG findings are more consistent with acute pericarditis. Anticoagulation should be avoided in acute pericarditis to prevent the development of hemorrhagic pericardial effusion.
(Choice C) Broad-spectrum antibiotics are indicated for bacterial pericarditis, but this condition is rare and commonly presents with high fever. This patient's recent MI makes PCIS more likely.
(Choice E) Nitroglycerin and beta blockers help relieve ischemic chest pain in acute MI but are not helpful in the treatment of pericarditis.
Educational objective:
Post–cardiac injury syndrome is an immunologic-mediated pericarditis that can occur several weeks to months following cardiac injury (eg, myocardial infarction). A nonsteroidal anti-inflammatory drug, usually high-dose aspirin, is the treatment of choice. Anticoagulation should be avoided to prevent the development of hemorrhagic pericardial effusion.