A 61-year-old man develops chest pain 3 days after admission for an anterior ST-elevation myocardial infarction. The new pain is sharp, worsens with deep inspiration and lying flat, and improves when he sits upright and leans forward. He denies dyspnea, nausea, or diaphoresis. He underwent successful percutaneous coronary intervention of the left anterior descending artery and has been symptom free until now. His medications include aspirin, ticagrelor, atorvastatin, metoprolol succinate, and lisinopril. Temperature is 37.7°C (99.9°F), blood pressure is 124/76 mm Hg, pulse is 88/min, and respiratory rate is 16/min. Cardiac examination reveals a scratchy, triphasic sound along the left sternal border. The lungs are clear. ECG demonstrates persistent Q waves from the recent infarction as well as new diffuse ST-segment elevations and PR-segment depressions. High-sensitivity troponin levels continue to decline. Transthoracic echocardiography shows a small pericardial effusion without right-sided chamber collapse.
Which of the following is the most appropriate treatment?
The correct answer is:
A) High-dose aspirin with colchicine
This patient has early post–myocardial infarction pericarditis. The pleuritic and positional chest pain, pericardial friction rub, diffuse ST-segment elevation, and PR-segment depression are characteristic of acute pericardial inflammation. The timing, within several days of a transmural infarction, suggests direct inflammation of the pericardium overlying necrotic myocardium rather than Dressler syndrome, which typically develops weeks to months later through an autoimmune mechanism.
High-dose aspirin is the preferred anti-inflammatory medication for pericarditis occurring shortly after myocardial infarction. Aspirin relieves pericardial inflammation while preserving the antiplatelet benefit required after acute coronary syndrome. Colchicine is often added because it improves symptom resolution and decreases the risk of recurrence.
The decreasing troponin concentration and absence of new regional ischemic ECG changes argue against reinfarction. Diffuse rather than territorial ST-segment elevation also favors pericarditis. The small effusion does not require drainage because there is no evidence of tamponade physiology.
Answer choice B: Ibuprofen with colchicine, is incorrect.
Ibuprofen is commonly used as first-line therapy for idiopathic or viral pericarditis and would therefore be reasonable in many patients. However, this patient developed pericarditis shortly after myocardial infarction. Nonaspirin NSAIDs may interfere with infarct healing and should generally be avoided in this setting. High-dose aspirin provides anti-inflammatory therapy while maintaining appropriate post-MI antiplatelet treatment.
Answer choice C: Intravenous heparin infusion, is incorrect.
Anticoagulation does not treat pericardial inflammation. In addition, unnecessary anticoagulation in a patient with a pericardial effusion may increase the risk of hemorrhagic effusion and tamponade.
Answer choice D: Prednisone monotherapy, is incorrect.
Corticosteroids can rapidly suppress pericardial inflammation but are generally reserved for patients with contraindications to aspirin and NSAIDs, specific autoimmune causes, or refractory disease. Early corticosteroid use increases recurrence risk and may impair healing of infarcted myocardium. This patient has no contraindication to aspirin.
Answer choice E: Repeat emergent coronary angiography, is incorrect.
Recurrent coronary occlusion would more likely cause pressure-like ischemic pain, territorial ECG changes, and a renewed increase in cardiac biomarkers. This patient’s pleuritic, positional pain, friction rub, diffuse ECG abnormalities, and falling troponin levels strongly support post-infarction pericarditis.
Key Learning Point
Early post–myocardial infarction pericarditis occurs within days due to inflammation overlying necrotic myocardium. High-dose aspirin with colchicine is preferred. Nonaspirin NSAIDs and corticosteroids are generally avoided because they may impair infarct healing or increase recurrence.
