Mon25October0844PM 17

A 72-year-old woman comes to the Emergency department ten days after discharge following stenting of the LAD and the mid-right coronary artery for critical stenoses. She complains of severe left sided and central pleuritic chest pain and increased shortness of breath.

Examination reveals a BP of 132/80 mmHg, pulse is 80 and regular, JVP is slightly elevated. There is no pericardial rub although heart sounds appear quiet.

Investigations reveal:

Hb 120 g/L (115-160)

WCC 10.3 ×109/L (4-10)

PLT 280 ×109/L (130-400)

Na 137 mmol/L (135-145)

K 4.7 mmol/L (3.5-5.5)

Cr 121 µmol/L (50-90)

CRP 110 (<10)

Troponin <0.05 -

ECG show widespread T wave inversion.

What is the most likely diagnosis?

(Please select 1 option)

Cardiac tamponade Incorrect answer selected

NSTEMI

Pulmonary embolus

Acute pericarditis This is the correct answer

Lower respiratory tract infection

Explanation

Pericarditis post angioplasty and stenting is well described, and can occur any time between 48 hours and two weeks after the procedure. The symptoms including pleuritic chest pain, elevated inflammatory markers, and non-specific ECG changes fit best with this diagnosis. Echocardiography is indicated to confirm the size of any pericardial effusion and there is no significant haemodynamic compromise. Treatment options include NSAIDs, colchicine and prednisolone.

The lack of significant haemodynamic compromise effectively rules out cardiac tamponade, and the normal troponin rules out NSTEMI. Whilst arterial rupture and consequent haemopericardium is seen, symptoms develop peri-procedure.

Pulmonary embolus may be a differential, but given patients undergoing PCI are mobilised quickly after procedure, and anti-coagulated, it is unlikely.