A 56-year-old hospitalized man is evaluated for recurrent chest pain. The patient was admitted 3 days ago due to a 1-day history of precordial chest pain. Evaluation revealed acute myocardial infarction and a drug-eluting stent was placed in the left anterior descending artery. His symptoms had resolved after the procedure but today the patient experienced sharp chest pain radiating to his left shoulder. He could only get comfortable sitting up but has had no orthopnea or palpitation. Current medications include aspirin, prasugrel, metoprolol, and rosuvastatin. Temperature is 37.2 C (99 F), blood pressure is 112/70 mm Hg, and pulse is 101/min and regular. Physical examination shows no heart murmurs and the lungs are clear bilaterally. ECG shows sinus tachycardia and widespread PR-segment depression. Which of the following is the best next step in management of this patient?

Question

A 56-year-old hospitalized man is evaluated for recurrent chest pain.  The patient was admitted 3 days ago due to a 1-day history of precordial chest pain.  Evaluation revealed acute myocardial infarction and a drug-eluting stent was placed in the left anterior descending artery.  His symptoms had resolved after the procedure but today the patient experienced sharp chest pain radiating to his left shoulder.  He could only get comfortable sitting up but has had no orthopnea or palpitation.  Current medications include aspirin, prasugrel, metoprolol, and rosuvastatin.  Temperature is 37.2 C (99 F), blood pressure is 112/70 mm Hg, and pulse is 101/min and regular.  Physical examination shows no heart murmurs and the lungs are clear bilaterally.  ECG shows sinus tachycardia and widespread PR-segment depression.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d30f_d64e_bc81_c767c0af2007_MD0003_00 This patient most likely has peri-infarction pericarditis (PIP). In contrast with post-cardiac injury (Dressler) syndrome, an immune-mediated pericarditis that typically occurs several weeks following myocardial injury, PIP results from local inflammation and typically occurs <4 days following myocardial infarction (MI). Patients with delayed coronary reperfusion following ST-segment elevation MI (eg, >3 hr from symptom onset) are at increased risk of developing PIP, as in this patient who initially presented with a 1-day history of chest pain. Like other types of pericarditis, PIP typically presents with pleuritic chest pain that improves with sitting upright and often radiates to the left shoulder or posteriorly to the bilateral scapulae. ECG commonly shows widespread ST-segment elevation and/or PR-segment depression. All patients suspected of having PIP should undergo echocardiography, which allows for characterization of any associated pericardial effusion and helps rule out other post-MI complications (eg, free wall rupture). Patients should be monitored for a pericardial effusion large enough to cause cardiac tamponade, even though it is rare with PIP. Treatment is usually supportive. Acetaminophen may be taken for pain control, but anti-inflammatory agents (eg, nonsteroidal anti-inflammatory drugs) are typically avoided for at least 7 days due to a possible increased risk of free wall rupture. (Choices A and E) Coronary angiography is indicated for suspected recurrent MI due to plaque rupture or stent thrombosis. However, such an event is unlikely to present as sharp, position-dependent chest pain and would not cause widespread PR-segment depression on ECG. Serum troponin level is often of limited use in evaluating recurrent post-MI chest pain as the level can remain elevated for up to 2 weeks following the initial MI. (Choice B) CT pulmonary angiography is indicated for suspected pulmonary embolism. Pleuritic chest pain can be present, but PIP is more likely with pain radiation to the left shoulder and in the setting of recent MI with delayed reperfusion. (Choice D) Exercise stress testing is used to evaluate suspected stable angina. Stable angina does not cause pleuritic chest pain and is unlikely in this patient who just underwent coronary angiography. Educational objective: Peri-infarction pericarditis (PIP) results from local inflammation following myocardial infarction (MI) and typically presents with pleuritic chest pain within 4 days of MI. All patients with suspected PIP should undergo echocardiography to characterize the presence and severity of any associated pericardial effusion and to rule out other post-MI complications (eg, free wall rupture). References: Regional pericarditis: a review of the pericardial manifestations of acute myocardial infarction. (http://www.ncbi.nlm.nih.gov/pubmed/19301285)

A 56-Year-Old Hospitalized Man Is Evaluated for Recurrent Chest Pain