A 64-year-old man hospitalized with acute myocardial infarction 3 days ago has chest pain that is worse on deep inspiration and radiates to the trapezius ridge. He underwent cardiac catheterization on admission and was found to have occlusion of the distal left anterior descending artery that could not be revascularized. He was treated with low-dose aspirin, clopidogrel, atorvastatin, metoprolol, and valsartan.
Physical examination shows a friction rub at the lower left sternal border.
Echocardiogram shows apical hypokinesis, left ventricular ejection fraction of 50%, and trivial pericardial effusion.
Which of the following is the best management for this patient?

Question

A 64-year-old man hospitalized with acute myocardial infarction 3 days ago has chest pain that is worse on deep inspiration and radiates to the trapezius ridge.  He underwent cardiac catheterization on admission and was found to have occlusion of the distal left anterior descending artery that could not be revascularized.  He was treated with low-dose aspirin, clopidogrel, atorvastatin, metoprolol, and valsartan.
Physical examination shows a friction rub at the lower left sternal border.
Echocardiogram shows apical hypokinesis, left ventricular ejection fraction of 50%, and trivial pericardial effusion.
Which of the following is the best management for this patient?

Quizplus · Accepted Answer

This patient's clinical presentation - recent myocardial infarction (MI), pleuritic chest pain with radiation to the shoulder, and a pericardial friction rub - is consistent with peri-infarction pericarditis (PIP). PIP usually occurs within days of MI and is more commonly seen in patients with no reperfusion. It is usually self-limiting, and current guidelines recommend the use of higher doses of aspirin (650 to 1000 mg three times per day) for symptomatic patients. Colchicine and/or narcotic analgesics can be used in combination with aspirin for symptomatic relief in patients with persistent symptoms despite higher doses of aspirin.(Choice A) Antiplatelet therapy with aspirin and clopidogrel plays an important role in management of patients with recent MI and should not be discontinued in patients with PIP. (Choice C) Anticoagulant therapy can be used in patients with uncomplicated PIP for appropriate indications (eg, atrial fibrillation, left ventricular thrombus). However, guidelines recommend that all anticoagulation (heparin or warfarin) should be discontinued in patients with PIP who develop a pericardial effusion due to risk of hemorrhagic effusion and cardiac tamponade. (Choices D and E) Glucocorticoids and nonsteroidal anti-inflammatory drugs (NSAIDs) are considered potentially harmful, with a risk of scar thinning, infarct expansion, or myocardial free wall rupture. They are not recommended for the treatment of PIP. NSAIDs (or corticosteroids in refractory cases) are used occasionally for symptomatic relief in patients with postcardiac injury syndrome (also known as Dressler's syndrome), which occurs weeks to months after an acute MI. Educational objective: Peri-infarction pericarditis refers to onset of acute pericarditis within days after an acute myocardial infarction. It is usually transient, and symptomatic patients should be managed with higher doses of aspirin. The use of anticoagulants, nonsteroidal anti-inflammatory drugs, and corticosteroids should be avoided in this setting. __________ References: 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/23256914)

A 64-Year-Old Man Hospitalized with Acute Myocardial Infarction 3 Days