Show notes
CardioNerds (Amit Goyal and Daniel Ambinder), join cardiology fellows from Indiana University cardiology fellows (Dr. Asad Torabi, Dr. Michelle Morris, and Dr. Sujoy Phookan) to discuss a case of a patient who developed a nagging cough post PCI and is ultimately diagnosed with Dressler Syndrome. This case describes the work up and management of post infarct pericarditis and briefly reviews the dilemma of utilizing triple anti-thrombotic therapy with high dose aspirin in the post myocardial infarction period. Indiana University faculty and expert, Dr. Julie Clary provides the E-CPR for this episode.
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Patient Summary
A 56-year-old man with recent anterior STEMI and new heart failure with reduced ejection fraction presented with fevers, persistent cough, and pleuritic chest pain following percutaneous coronary intervention for the past two weeks. He was ultimately found to have post cardiac injury syndrome - post infarct pericarditis (formerly known as Dressler syndrome) with elevated inflammatory markers, a small pericardial effusion, and incidentally noted to have an apical left ventricular thrombus. This case describes the work up and management of post infarct pericarditis and briefly reviews the dilemma of utilizing triple anti-thrombotic therapy with high dose aspirin in the post myocardial infarction period.
Case Media
CXREKGClick to Enlarge
Episode Teaching
Pearls
1. Post cardiac injury syndrome (PCIS) following myocardial infarction can be very debilitating and recurrence is the concern when treatment is not pursued.
2. Acute pericarditis is a clinical diagnosis which does not require imaging and can have a wide spectrum on presentation ranging from fever/cough to the classic positional chest pain.
3. PCIS following myocardial infarction is less common in the post PCI era but we are starting to see more cases in late presenters.
4. We have good level of evidence to suggest the use of colchicine to reduce the recurrence of PCIS. COPPS and COPPS-2, are two such randomized placebo control trials, which show benefit in the cardiac surgical patient.
5. While triple therapy on high dose aspirin is not discussed in the 2013 ACCF/AHA STEMI guidelines, carefully assess your patient’s bleeding risk and invoke patient shared decision making whenever possible.
Notes
1. What is Post-Cardiac Injury Syndrome (PCIS) and what are the clinical manifestations?
PCIS is an umbrella term for specific clinical scenarios which may result in symptomatic acute pericarditis.PCIS encompasses:Post-myocardial infarction pericarditis which may be early or late (Dressler syndrome – the focus of this case)Post-pericardiotomy syndrome (PPS)Post-traumatic pericarditis including traumatic and iatrogenic (following most percutaneous procedures such as ablations, PCI, lead placement, etc).
2. How is PCIS (or post infarct pericarditis) diagnosed?
This is a clinical diagnosis, made when ≥ 2 of the following are present:Fever without alternative causePericarditic or pleuritic chest painFriction rubPericardial effusionPleural effusion with elevated CRPNote this is different from the diagnostic criteria for other causes of acute pericarditis which requires 2 of the 4 following features:Pericarditic chest painFriction rubNew widespread ST-elevations or PR depressions on ECGPericardial effusion (new or worsening)Supporting findings for pericarditis include:Elevation of inflammatory markers (CRP, ESR, WBC)Pericardial inflammation on cross sectional cardiac imaging (CT, CMR)
3. What are the complications of not treating Dressler syndrome?
Imazio et al published an excellent case series in 2009 which answers this question. Overall the prevalence of complications for early and late post-infarct pericarditis was low. No cases of constrictive pericarditis were observed but the incidence of recurrent pericarditis was observed at 3.2%.The 2015 ESC pericardial guidelines recommend considering careful follow-up after PCIS to exclude possible evolution towards constrictive pericarditis with echocardiography every 6-12 months according to clinical features and symptoms (Class IIa).
4. What is the evidence for high dose Aspirin in Dressler syndrome?
This is a class 1b evidence in the 2013 ACCF/AHA STEMI guidelines. This evidence comes from data from a small case series of 24 patients which compared aspirin to indomethacin head-to-head. Overall aspirin was non-inferior with similar bleeding risk. The guidelines recommend the use of high dose aspirin because of NSAIDS may interfere with DAPT and there is also concern regarding scar thinning and infarct expansion. The 2015 ESC pericardial guidelines recommend aspirin as a first choice for anti-inflammatory therapy of post-myocardial infarction pericarditis and those who are already on antiplatelet therapies (Class I).
5. What is the role of colchicine for MI, for chronic coronary disease, for pericarditis, and for PCIS?
Following MI (without pericarditis): the COLCOT trial showed that colchicine is effective at preventing major adverse cardiac events after MI. In this randomized, double-blind, placebo-controlled trial, a total of 4,745 patients (within 30 days of MI and following intended coronary revascularization) were randomized to colchicine 0.5mg daily or to placebo. After a median follow-up of 22.6 months, there was a significant reduction in the primary efficacy outcome (cardiovascular death, MI, CVA, resuscitated cardiac arrest, or urgent hospitalization for UA leading to revascularization) (HR 0.77, 95% CI 0.61-0.96, p = 0.02).Chronic coronary disease (without pericarditis): the LoDoCo2 trial showed that colchicine is effective in reducing major adverse cardiac events in patients with chronic coronary disease. In this randomized, double-blind, placebo-controlled trial, a total of 5,522 patients were randomized to colchicine 0.5mg daily or to placebo. After a median follow-up of 28.6 months, there was a significant reduction in CV mortality, MI, ischemic stroke, or coronary revascularization driven by ischemia events in the treatment arm (HR 0.69, 95% CI 0.57-0.83, p