A 62-year-old man presents to the emergency department with chest pain and shortness of breath that he experienced while barbecuing. The pain is over his chest and in his left arm. The patient has a medical history of obesity, type 2 diabetes mellitus, and hypertension. His current medications include insulin, metformin, lisinopril, and hydrochlorothiazide. An ECG is performed and is seen in Figure A. His temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air. The patient is appropriately managed and is admitted to the step-down unit. 2 days later, he complains of chest pain. A repeat ECG is performed and is seen in Figure B. Which of the following is the most appropriate next step in management for this patient's underlying condition?
Prednisone
Aspirin
Stenting
Ibuprofen
Aspirin
This patient is presenting with chest pain several days after sustaining a myocardial infarction and has an ECG suggestive of pericarditis. This presentation is consistent with Dressler syndrome and the most appropriate initial step in management is aspirin.

Dressler syndrome is pericarditis that can occur after a myocardial infarction (MI). It most commonly occurs weeks to months after the MI, but can also occur within 1 week from an MI in rare cases. It is believed to result from an autoimmune reaction that occurs after damage to the heart (surgery and MI). It presents with chest pain, fever, pleuritic pain, and a pericardial friction rub. ECG demonstrates diffuse ST elevation with PR depression consistent with pericarditis. The most appropriate initial step in the management of this condition is symptomatic management with aspirin.

Leib et al. review the evidence regarding the diagnosis and treatment of Dressler syndrome. They discuss how this condition is secondary pericarditis with or without pericardial effusion resulting from injury to the heart or pericardium. They recommend considering this syndrome in all patients with chest pain after a myocardial infarction.

Figure/Illustration A demonstrates an ECG with ST elevation in leads II, III, and aVF (blue circles) suggesting a diagnosis of right-sided MI.

Figure/Illustration B demonstrates an ECG with diffuse ST elevation and PR depression (blue circles) suggesting a diagnosis of pericarditis.

Incorrect Answers:
Answers 1 & 5: Angiography and stenting would be appropriate management if this patient were experiencing a repeat MI. The diffuse ST elevation and PR depression seen several days after his myocardial infarction are more indicative of pericarditis rather than a repeat MI. In addition, the chest pain the patient is experiencing can also occur in pericarditis and obfuscates the diagnosis of repeat MI.

Answers 3 & 4: Ibuprofen, other NSAIDs, and corticosteroids such as prednisone are not first-line therapy in post-MI pericarditis as they can hinder the healing and remodeling process of the myocardium. Current guidelines dictate that they may be used in cases that are refractory to initial therapy.

Bullet Summary:
Dressler syndrome (post-MI pericarditis) presents with chest pain, pericardial friction rub, fever, and diffuse ST elevation with PR depression on ECG, and should be treated initially with aspirin.