Post-MI Pericarditis

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ITE Round Up: Post MI Pericarditis

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You are managing a patient in CVICU who is 2 days s/p PCI to LAD after presenting with STEMI. He is now describing chest pain that improves with leaning forward. You think you hear a cardiac rub. You have obtained the above ECG. How will you treat this patient?

We often think about STEMIs as a single vessel problem, we describe the pathology using terms like “target lesion” but there is a significant systemic inflammatory component to an MI that we overlook. When thinking about the complications of an MI we can break it down into two categories - mechanical complications (ruptures of all sorts depending on the amount of tissue necrosis) and inflammatory/immunologic (pericarditidis of all sorts).

First things first, how do we diagnose pericarditis?

  • Chest pain – Typically sharp, pleuritic, and centrally located; the pain is improved by sitting up and leaning forward.

  • Pericardial friction rub – A superficial scratchy or squeaking sound best heard with the diaphragm of the stethoscope over the left sternal border; the rub is frequently intermittent and may be difficult to appreciate, but is diagnostic when present.

  • ECG changes – New widespread ST elevation and/or PR depression which extend beyond a typical anatomic regional boundary.

  • Pericardial effusion – Most effusions are small and not hemodynamically significant

Next. Is this Dresslers Syndrome or Peri-Infarction Pericarditis (PIP)? You can use timeline to help with this. Dressler’s is a delayed response after several weeks. How do we treat these?

PIP is usually a self-limited process related to inflammation from an MI. If symptoms are prolonged past a week, ASA 650mg q6-8h is recommended. There is no role in colchicine or glucocorticoids.

Dressler’s is treated similarly to acute pericarditis - NSAIDs (ASA or Ibu), colchicine is an option, glucocorticoids.

Gene Novikov, MD