Post cardiac injury syndrome

Synonyms and keywords: PCIS

Overview
Post cardiac injury syndrome (PCIS) encompasses two causes of pericarditis:
 * 1) Post myocardial infarction syndrome (PMIS) or Dressler's syndrome and
 * 2) Postpericardiotomy syndrome (PCS)

Pathophysiology
Both syndromes represent the delayed occurrence of pericarditis. Post-myocardial infarction syndrome is obviously due to myocardial infarction and postpericardiotomy syndrome is due to the myocardial injury that occurs during cardiac surgery. Both syndromes are thought to represent an autoimmune process with the development of anti-heart antibodies.

Natural History, Complications and Prognosis
Most often the course of PCIS is benign. Rare complications include development of cardiac tamponade, pericardial constriction, and saphenous vein graft occlusion.

Symptoms
Both syndromes share common symptoms which include fever and pleuritic pain.

Physical Examination
The following findings may be present:

Cardiovascular
A pericardial friction rub

Lungs
A pleural effusion

Laboratory Studies
The following lab abnormalities may be present:
 * An elevated erythrocyte sedimentation rate.
 * A leukocytosis.

Chest x-ray
A pleural effusion with or without pulmonary infiltrates may be present.

Treatment
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

===ACC/AHA Treatment Guidelines (DO NOT EDIT) ===

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Class I
1. Aspirin is recommended for treatment of pericarditis after STEMI. Doses as high as 650 mg orally (entericcoated) every 4 to 6 hours may be needed. (Level of Evidence: B)

2. Anticoagulation should be immediately discontinued if pericardial effusion develops or increases. (Level of Evidence: C)

Class IIa
1. For episodes of pericarditis after STEMI that are not adequately controlled with aspirin, it is reasonable to administer 1 or more of the following:
 * a. Colchicine 0.6 mg orally every 12 hours (Level of Evidence: B)
 * b. Acetaminophen 500 mg orally every 6 hours. (Level of Evidence: C)

Class IIb
1. Corticosteroids might be considered only as a last resort in patients with pericarditis refractory to aspirin or NSAIDs. Although corticosteroids are effective for pain relief, their use is associated with an increased risk of scar thinning and myocardial rupture. (Level of Evidence: C)

2. Nonsteroidal anti-inflammatory drugs may be considered for pain relief; however, they should not be used for extended periods because of their effect on platelet function, an increased risk of myocardial scar thinning, and infarct expansion. (Level of Evidence: B)

Class III
1. Ibuprofen should not be used for pain relief because it blocks the antiplatelet effect of aspirin and it can cause myocardial scar thinning and infarct expansion. (Level of Evidence: B) }}