What is the cause of chest pain, shortness of breath (SOB), and nausea radiating to the left back 3 days after percutaneous coronary intervention (PCI)?

From the Guidelines

This presentation of chest pain radiating to the left back, accompanied by shortness of breath and nausea occurring 3 days after percutaneous coronary intervention (PCI) requires immediate emergency evaluation. The patient should call 911 or go to the emergency department immediately as these symptoms suggest possible acute coronary syndrome, stent thrombosis, or other serious post-PCI complications. While waiting for emergency services, the patient should take 325mg of aspirin (if not contraindicated and not already on high-dose antiplatelet therapy) 1. The patient should not discontinue any prescribed post-PCI medications such as dual antiplatelet therapy (typically aspirin plus a P2Y12 inhibitor like clopidogrel, ticagrelor, or prasugrel). This urgent recommendation is based on the timing and nature of symptoms, which are concerning for acute stent thrombosis (which peaks in risk at 24-72 hours post-procedure) or other complications like pericarditis, coronary artery dissection, or myocardial infarction, as defined by the third universal definition of myocardial infarction 1.

The radiation to the back could also indicate aortic complications. Post-PCI chest pain requires thorough evaluation including ECG, cardiac enzymes, and possibly repeat coronary angiography to ensure the recently placed stent remains patent and functioning properly. According to the guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction, patients with chest pain or severe epigastric pain, nontraumatic in origin, with components typical of myocardial ischemia or MI, should undergo immediate assessment and possibly initiation of the ACS protocol 1.

Key considerations in the evaluation of this patient include:

• The patient's recent history of PCI and the potential for stent thrombosis or other complications
• The presence of symptoms suggestive of myocardial ischemia, such as chest pain radiating to the left back, shortness of breath, and nausea
• The need for immediate emergency evaluation and potential initiation of the ACS protocol
• The importance of not discontinuing prescribed post-PCI medications, such as dual antiplatelet therapy.

Overall, the patient's symptoms and recent medical history suggest a high risk for serious complications, and immediate emergency evaluation is necessary to determine the cause of the symptoms and provide appropriate treatment.

From the Research

Possible Causes of Symptoms

• Chest pain, shortness of breath (SOB), and nausea radiating to the left back 3 days after percutaneous coronary intervention (PCI) may be caused by acute pericarditis, as reported in a case study 2
• The symptoms presented are consistent with pericarditic chest pain, typical ECG findings, and pericardial effusion with elevated C-reactive protein, which are indicative of acute pericarditis 2
• Other possible causes of these symptoms are not directly supported by the provided evidence, but may include complications related to the PCI procedure or underlying coronary artery disease

Relationship to PCI Procedure

• Acute pericarditis is a rare complication of PCI, and may occur despite the lack of specific clinical manifestation or procedure-related complications 2
• The timing of the symptoms, 3 days after PCI, is consistent with the development of acute pericarditis, which can occur early after the procedure 2
• The use of antithrombotic strategies, such as dual antiplatelet therapy, may be important in reducing the risk of thrombotic complications after PCI, but is not directly related to the development of acute pericarditis 3

Diagnostic Considerations

• The diagnosis of acute pericarditis is based on clinical presentation, ECG findings, and laboratory results, including elevated C-reactive protein and pericardial effusion 2
• The presence of chest pain, SOB, and nausea radiating to the left back, in combination with ECG findings and laboratory results, should prompt consideration of acute pericarditis as a possible diagnosis 2
• Further evaluation, including imaging studies and laboratory tests, may be necessary to confirm the diagnosis and rule out other possible causes of the symptoms 2