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

The patient should call 911 or go to the emergency department immediately as these symptoms could indicate serious complications such as acute stent thrombosis, pericarditis, or myocardial infarction, specifically type 4a myocardial infarction related to PCI, as defined by the third universal definition of myocardial infarction 1. The presentation of chest pain radiating to the left back, shortness of breath, and nausea occurring 3 days after percutaneous coronary intervention (PCI) is concerning for several potential complications.

• The symptoms could be indicative of acute stent thrombosis, which is a life-threatening complication that can occur within days of the procedure and presents with recurrent chest pain.
• Other possibilities include pericarditis (inflammation of the heart lining), coronary artery dissection, or even non-cardiac causes like pulmonary embolism.
• The combination of chest pain radiating to the back with shortness of breath and nausea represents a concerning constellation of symptoms that requires prompt medical attention to prevent serious cardiovascular complications. While awaiting emergency services, the patient should take 325mg of aspirin if not contraindicated and continue any prescribed antiplatelet medications (such as clopidogrel, ticagrelor, or prasugrel) as recommended by the guidelines for myocardial infarction related to PCI 1. The patient should not drive themselves to the hospital, and emergency evaluation should include measurement of cardiac biomarkers, ECG, and imaging studies to determine the cause of the symptoms and guide further management, according to the universal definition of myocardial infarction 1.
• The diagnosis of type 4a myocardial infarction related to PCI is arbitrarily defined by elevation of cTn values >5 x 99th percentile URL in patients with normal baseline values (<99th percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling, along with symptoms suggestive of myocardial ischemia, new ischemic ECG changes or new LBBB, or angiographic evidence of a flow limiting complication 1.
• The patient's symptoms and history of recent PCI warrant immediate attention to rule out these potential complications and initiate appropriate treatment to prevent serious morbidity and mortality.

From the Research

Possible Causes of Symptoms

The symptoms of chest pain, shortness of breath (SOB), and nausea radiating to the left back 3 days after percutaneous coronary intervention (PCI) can be caused by several factors, including:

• Acute stent thrombosis (AST) caused by coronary artery spasms 2
• Acute pericarditis, a rare complication of PCI 3
• Cardio-cerebral infarction (CCI), a rare occurrence of acute myocardial infarction (AMI) and acute ischemic stroke (AIS) 4

Risk Factors for Stent Thrombosis

The risk factors for stent thrombosis after PCI include:

• Use of stents of inappropriate diameters, multiple overlapping stents, or excessively long stents
• Incomplete stent expansion
• Poor stent adhesion
• Incomplete coverage of dissection
• Formation of thrombosis or intramural hematomas
• Vascular injury secondary to intraoperative mechanical manipulation
• Insufficient dose administration of postoperative antiplatelet medications
• Resistance to antiplatelet drugs 2

Predictors of Stent Thrombosis

The predictors of stent thrombosis after PCI in acute myocardial infarction include:

• Pre-randomization heparin
• A 600-mg clopidogrel loading dose 5

Treatment Options

The treatment options for the symptoms include:

• Percutaneous transluminal coronary angioplasty for AST caused by coronary artery spasms 2
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for acute pericarditis 3
• Primary percutaneous coronary intervention for cardio-cerebral infarction 4