WBR0018

Jump to navigation Jump to search


Author Aarti Narayan MBBS, Raviteja Reddy Guddeti MBBS (Reviewed by Gonzalo Romero)
Exam Type USMLE Step 2 CK
Main Category Internal medicine
Sub Category Cardiovascular
Prompt A-52-year old female undergoes percutaneous coronary intervention at a local community hospital. 5 weeks following discharge, she presents to her primary care physician complaining of sharp retrosternal chest pain, aggravated when lying flat and inspiration, and relieved when sitting up. What is the treatment of choice of the most likely diagnosis?
Answer A Corticosteroids
Answer A Explanation Corticosteroids are not the treatment of choice in Dressler's syndrome. Glucocorticoids and nonsteroidal antiinflammatory drugs are potentially harmful for treatment of pericarditis after STEMI.
Answer B Aspirin
Answer B Explanation Is the treatment of choice to treat Dressler's syndrome.
Answer C Morphine
Answer C Explanation [[AnswerCExp::Administration of acetaminophen, colchicine, or narcotic analgesics may be reasonable if aspirin, even in higher doses, is not effective.]]
Answer D Colchicine
Answer D Explanation Administration of acetaminophen, colchicine, or narcotic analgesics may be reasonable if aspirin, even in higher doses, is not effective.
Answer E Rest
Answer E Explanation Rest alone will not treat Dressler's syndrome. Pharmacological therapy with aspirin is the recommended drug of choice.
Right Answer B
Explanation [[Explanation::This patient is returning to the office due to Dressler's syndrome, which is a post myocardial infarction syndrome. It is a form of fibrinous pericarditis that occurs in the setting of injury to the heart (myocardial infarction). Typically, it occurs 2 to 10 weeks following a myocardial infarction. This differentiates Dressler's syndrome from the much more common post myocardial infarction pericarditis that occurs in 17 to 25% of cases of acute myocardial infarction between days 2 and 4 after the myocardial infarction. Dressler's syndrome also needs to be differentiated from pulmonary embolism, another identifiable cause of pleuritic (and non-pleuritic) chest pain in people who have been hospitalized and/or undergone surgical procedures within the preceding weeks.

It is believed to result from an autoimmune inflammatory reaction to myocardial neo-antigens.

Dressler's syndrome is typically treated with high dose (up to 650 mg PO q 4 to 6 hours) enteric-coated aspirin. Acetominophen can be added for pain management as this does not affect the coagulation system. Anticoagulants should be discontinued if the patient develops a pericardial effusion.

NSAIDs such as ibuprofen should be avoided in the peri-infarct period as they:

  1. Increase the risk of reinfarction
  2. Adversely impact left ventricular remodeling
  3. Block the effectiveness of aspirin

Educational Objective: Dressler's syndrome is a form of pericarditis that presents 2 to 10 weeks following a myocardial infarction. The treatment of choice is high dose enteric coded aspirin. Administration of acetaminophen, colchicine, or narcotic analgesics may be reasonable if aspirin, even in higher doses, is not effective.
References: O'Gara PT, Kushner FG, Ascheim DD, et al. (December 2012). "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology]]

Approved Yes
Keyword MI, Pericarditis, Aspirin, NSAIDs, Dressler's syndrome
Linked Question
Order in Linked Questions