A 64-year-old man comes to the emergency department due to chest pain. Two weeks ago, he was hospitalized for an acute myocardial infarction, and he is afraid his heart attack is recurring. He localizes the pain to the middle of the chest and says that he can only take shallow breaths because deep breaths make the pain worse. Leaning forward in his chair makes the pain somewhat better. He notes some 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 shows ST segment elevations in all limb and precordial leads except in aVR, where ST depression is seen. Which of the following is the best next step in the management of this patient?

Question

A 64-year-old man comes to the emergency department due to chest pain.  Two weeks ago, he was hospitalized for an acute myocardial infarction, and he is afraid his heart attack is recurring.  He localizes the pain to the middle of the chest and says that he can only take shallow breaths because deep breaths make the pain worse.  Leaning forward in his chair makes the pain somewhat better.  He notes some 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 shows ST segment elevations in all limb and precordial leads except in aVR, where ST depression is seen.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

The patient's chest pain characteristics (worse with deep inspiration, improved on leaning forward) and ECG findings (diffuse ST elevation with reciprocal depression in AVR) are consistent with pericarditis. Given his recent hospitalization, He most likely has post-cardiac injury syndrome (PCIS, Dressler syndrome), a pericarditis that can occur weeks after myocardial infarction (MI). PCIS represents an immunologic response to damaged mesothelial pericardial cells and blood in the pericardial space. Malaise and sometimes fever are also characteristic. The erythrocyte sedimentation rate is typically elevated. High-dose nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy (eg, aspirin 1000 mg or ibuprofen 800 mg every 6-8 hours); they are usually given with colchicine (which is sometimes prescribed prophylactically in patients undergoing cardiac surgery), although data are limited. Anticoagulation should be avoided to prevent development of a hemorrhagic pericardial effusion. Corticosteroids can be used in refractory cases or when NSAIDs are contraindicated. In contrast to PCIS, peri-infarct pericarditis usually develops within days (rather than weeks) of MI and is self-limited; if it develops, management generally includes avoidance of NSAIDs (other than aspirin) for 7-10 days. (Choice A) Anticoagulation with heparin would be appropriate if this patient was having another MI, but the characteristics of his pain as well as the ECG findings are more suggestive of pericarditis. (Choice B) Warfarin is used for long-term anticoagulation, and should probably be avoided in a patient with pericarditis to prevent the development of a hemorrhagic pericardial effusion. (Choice C) Nitroglycerin and beta blockers are treatments for MI, but are not helpful in the treatment of pericarditis. (Choice D) Broad-spectrum antibiotics are not indicated for PCIS since it is caused by an immunologic abnormality and not infection. Educational objective: Post-cardiac injury syndrome (Dressler syndrome) presents weeks after a myocardial infarction with chest pain that is improved by leaning forward. Nonsteroidal anti-inflammatory drugs are the treatment of choice and are usually administered with colchicine. Anticoagulation should be avoided to prevent development of a hemorrhagic pericardial effusion.

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