Review Question - QID 102971

A patient developing pleuritic chest pain 1-4 days after CABG, with pain that is relieved by sitting up/forward and an ECG significant for PR depression in the precordial leads is most likely acute pericarditis.

There are many complications that can occur post-MI and cardiac surgery. One to five days after MI, patients complications include acute pericarditis, papillary muscle rupture, and ventricular septal rupture. Over a longer time period, patients may suffer from pericarditis due to an autoimmune reaction, called Dressler's Syndrome, along with remodeling of the ventricular wall leading to a ventricular aneurysm. Both acute pericarditis and Dressler's syndrome, though differing in time of onset, are treated initially with NSAIDs.

Snyder et al. review the topic of acute pericarditis. They state that acute pericarditis has many etiologies, such as infection, acute myocardial infarction, medication use, trauma to the thoracic cavity, and systemic diseases such as rheumatoid arthritis. Additionally, they state that a pericardial friction rub can found in up to 85% of patients with acute pericarditis. The most specific finding for pericarditis on ECG is PR depressions in the precordial leads, with the first-line treatment including NSAIDs and colchicine (with glucocorticoids reserved for refractory cases).

Kyto et al. report on demographics and outcomes for patients admitted for acute pericarditis. They state that men 16 to 65 years of age were at higher risk for pericarditis (RR, 2.02, P<0.0001) than women in the general population. They also state that mortality associated with acute pericarditis increased with age (HR, 3.26 per 10 year increase in age, P=0.0001) and severe coinfection (pneumonia or septicemia; HR, 13.46, P<0.005).

Figure A shows an ECG with ST elevations in all the leads, along with PR depressions in the precordial leads signifying acute pericarditis.

Incorrect Answers:
Answer 1: Ventricular aneurysms typically occur weeks to months after MIs and present with persistent ST elevations along the same distribution as the original MI and potential embolic phenomenon such as strokes.
Answer 2: Ventricular septal ruptures can acutely present with uncompensated heart failure but more typically present with dyspnea in the setting of a new holosystolic murmur along the lower left sternal border.
Answer 3: Papillary muscle rupture typically presents with a new holosystolic murmur best appreciated at the apex with radiation to the axilla.
Answer 5: Dressler's syndrome can present similarly to acute pericarditis but typically occurs weeks to months after the initial insult.