A 64-year-old man comes to the emergency department due to chest pain. The pain is sharp, localized to the anterior chest, and exacerbated by deep breathing. Six weeks ago, the patient underwent coronary artery bypass graft surgery due to stable triple-vessel coronary artery disease. The patient also has a history of type 2 diabetes mellitus and early-stage chronic kidney disease. Temperature is 38 C (100.4 F), blood pressure is 144/78 mm Hg, and pulse is 99/min and regular. The sternal wound appears unremarkable, and there is no crepitus on palpation. No heart murmurs are heard. Breath sounds are normal. ECG shows sinus tachycardia with nonspecific ST-segment changes. Laboratory results are as follows: Echocardiography shows normal biventricular function, no significant valvular disease, and a small pericardial effusion without evidence of cardiac compression. What is the most likely cause of this patient's current presentation?

Question

A 64-year-old man comes to the emergency department due to chest pain.  The pain is sharp, localized to the anterior chest, and exacerbated by deep breathing.  Six weeks ago, the patient underwent coronary artery bypass graft surgery due to stable triple-vessel coronary artery disease.  The patient also has a history of type 2 diabetes mellitus and early-stage chronic kidney disease.  Temperature is 38 C (100.4 F), blood pressure is 144/78 mm Hg, and pulse is 99/min and regular.  The sternal wound appears unremarkable, and there is no crepitus on palpation.  No heart murmurs are heard.  Breath sounds are normal.  ECG shows sinus tachycardia with nonspecific ST-segment changes.  Laboratory results are as follows:  Echocardiography shows normal biventricular function, no significant valvular disease, and a small pericardial effusion without evidence of cardiac compression.  What is the most likely cause of this patient's current presentation?

Quizplus · Accepted Answer

11ec25c8_d32b_e9ef_bc81_653cb24ff5be_MD0003_00 This patient with pleuritic chest pain occurring several weeks after coronary artery bypass graft (CABG) surgery most likely has acute pericarditis due to post-cardiac injury syndrome (PCIS). This condition results from immune-complex deposition in the pericardium and pleura that can occur following any event or intervention (eg, myocardial infarction, CABG surgery, percutaneous coronary intervention) that facilitates immune system exposure to cardiac antigens. When it occurs following myocardial infarction specifically, it is often called Dressler syndrome. PCIS is characterized by a latent period of several weeks to months from the time of cardiac injury to presentation of symptoms. It presents like other types of acute pericarditis; in addition to pleuritic chest pain, patients may have fever, leukocytosis, elevated inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein), and pleural effusion on chest x-ray. ECG findings are usually nonspecific, as in this patient, but may demonstrate the classic widespread ST-segment elevation associated with acute pericarditis. Pericardial effusion is usually present and should be evaluated with echocardiography. The diagnosis is made based on a consistent clinical picture. Treatment of PCIS is usually with nonsteroidal anti-inflammatory drugs plus colchicine; corticosteroids are reserved for cases refractory to initial therapy. Colchicine monotherapy can also be effective in preventing PCIS when administered following cardiac surgery. The course of PCIS is typically self-limited; however, a small percentage of patients can experience a chronic course with multiple disease recurrences that can lead to constrictive pericarditis. (Choice A) Bacterial mediastinitis, a serious complication of CABG surgery, usually presents with fever, chest pain, and incisional purulence, dehiscence, or crepitus within 2 weeks of surgery. It is unlikely in this patient with a normal wound appearance 6 weeks after cardiac surgery. (Choice B) Hemopericardium can result from ventricular free wall rupture following myocardial infarction. It typically leads to cardiac tamponade, which is unlikely in the absence of hypotension. (Choice D) Venous graft failure following CABG surgery typically presents with a recurrence of symptoms of stable angina (eg, exertional pressure-like chest pain). Pleuritic chest pain is not expected. (Choice E) Viral infection is considered the most common cause of acute pericarditis, but PCIS is more likely in this patient who had CABG surgery 6 weeks ago. Educational objective: Post-cardiac injury syndrome is a form of acute pericarditis that results from immune-complex deposition in the pericardium. It can occur following any event or intervention (eg, myocardial infarction, coronary artery bypass graft surgery, percutaneous coronary intervention) that exposes the immune system to cardiac antigens and typically has a latency period of several weeks to months. References: Post-cardiac injury syndromes. An emerging cause of pericardial disease. (http://www.ncbi.nlm.nih.gov/pubmed/23040075) Contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21798503)

A 64-Year-Old Man Comes to the Emergency Department Due to Chest