Question of the Week # 164

164) A 64 year old man is seen in the Emergency room for sharp sub sternal chest pain that started few hours ago. The pain increases on coughing and deep breathing. His history is significant for Acute Myocardial Infarction about 6 weeks ago. At that time, he was treated with percutaneous coronary intervention and stent placement. On physical examination, temperature is 100F, Heart rate 88/min, and Blood pressure 110/70 mm Hg. Pulsus paradoxus is 8mm Hg and lungs are clear to auscultation. A chest X-ray reveals enlargement of cardiac shadow. The most appropriate treatment for this patient’s presentation:

A) Pericardiocentesis

B) Oral Ibuprofen

C) Oral Prednisone

D) Metoprolol

E) Cardiac catheterization to evaluate stent re-occlusion

9 Responses

  1. B) Oral Ibuprofen

  2. b

  3. B) Oral Ibuprofen

  4. the cardiac shadow is increased only if there is fluid but i guess the patient is shadow so we can give trial of ibuprofen or better would be do echo and decide amount of fluid since patient is in er and treat according to the guidelines

  5. bbb

  6. C) Oral Prednisone

    Its 6 weeks post MI – Dressler’s Syndrome

    • Dressler’s syndrome is typically treated with NSAIDs such as aspirin or with corticosteroids.[9] However corticosteroids are reserved for rare cases and are seldom required

  7. B………

  8. This patient has two risk factors for Dressler’s syndrome. One is acute MI and second is percutaneous intervention (pericardial injury) Both conditions elicit reparative inflammatory response, sometimes excessive, which can lead to pericardial effusion in 1-6 weeks.
    As typical with pericarditis this condition gives fever and pleuritic chest pain.

    Evidence that heart function is normal – clear lungs, normal blood pressure and heart rate.
    Abnormalities – pleuritic chest pain and enlarged cardiac shadow

    Another finding that suggests normal heart function and more;
    RULES OUT CARDIAC EMBARASSMENT:
    ‘Pulsus paradoxes is 8mmHg and lungs are clear’ – means that the diastolic pressure and volume in the left ventricle are not high enough to off set the normal response (elevation of pulsus paradoxes > 10mmHg) in the event of a cardiac tamponade. Hence this patient is not an exception and Pulsus paradoxes is a reliable predictor of cardiac tamponade in this patient and it reliably predicts the degree of hemodynamics embarrassment from pericardial effusion. Right now, this patient doesn’t even have mild tamponade even with an enlarged cardiac shadow. His delta SYST is less than experimental controls! (12) Pulsus paradoxes > 25 mmHg signify moderate to severe tamponade.
    http://www.ncbi.nlm.nih.gov/pubmed/3341174?dopt=Abstract
    SUGGESTS NORMAL HEART FUNCTION:
    Pulsus paradoxes (delta SYST) of 8 mmHg and clear lung examination suggest good afterload function of the heart ( normal left ventricular function, and normal right ventricular function also, since right sided tension pneumothorax is also ruled out) and it also excludes hemodynamics embarrassment from pericardial effusion.

    A, heart function is normal, I will not expose this patient to the risks of surgical intervention ( hepatic injury, gastric perforation, myocardial injury, coronary artery puncture or aneurysm, internal mammary artery puncture or aneurysm, pneumothorax, hemothorax, dysrrhythmias) Risk of complications is 4 – 40%. It is not necessary now.

    B,(my answer) I would preferred aspirin first, but NSAID (ibuprofen) will relieve symptoms and inflammation. All NSAIDs (except aspirin) are pro thrombotic (increase risk for heart attacks and strokes) and in 2005, FDA recognized this and included this information on all NSAID drug labels except aspirin. NSAIDS (except aspirin) should be avoided in Ischemic heart disease. If this patient had MI from ischemic heart disease (statistically more likely), I would avoid all NSAIDs except aspirin. But non selective COX inhibitor (ibuprofen) is still better than selective COX inhibitors. Ibuprofen would be my choice if this patient is refractory to aspirin. It is however the best or most appropriate treatment for Dressler’s syndrome in this patient (in the listed options)
    http://circ.ahajournals.org/content/117/17/e322.full
    http://en.wikipedia.org/wiki/Dressler's_syndrome, randomized trials have not supported use of colchicine yet.

    C,Corticosteroids produce rapid improvement in clinical symptoms and decrease in anti-heart antibodies. But there is high frequency of relapse when it is discontinued. I would reserve this for severe or refractory cases of Dressler’s syndrome.

    D, Metoprolol is not the most appropriate treatment for Dressler’s syndrome. It will reduce mortality after acute MI but it will not stop the progression of Pericardial effusion, which happens to be the priority right now. Here is a link to some more interesting information on the use of B-blockers in Post-MI patients; (published by AHA)
    http://circ.ahajournals.org/content/106/4/394.full

    E, Cardiac catheterization to evaluate stent re-occlusion, this will not relieve the symptoms, even if one is tempted to think that another percutaneous coronary angiography will create a pericardial window.
    This procedure is not indicated. There is no objective evidence in the question to suggest that this patient has a stent re-occlusion. The likihood ratio for pleuritic chest pain causing ACS or AMI is less than one, meaning it is more likely associated with absence of the disease
    http://www.ncbi.nlm.nih.gov/pubmed/16304077
    This option is not the most appropriate treatment for Dressler’s syndrome and it is not the most appropriate treatment option without conclusive diagnostic findings like ST elevation or elevated CK-MB.

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