What is the best treatment for a patient with pleuritis and a cardiac stent (coronary artery stent)?

Treatment of Pleuritis in Patients with Coronary Stents

For a patient with pleuritis and a coronary stent, NSAIDs should be avoided due to increased cardiovascular risk, and treatment should focus on corticosteroids while maintaining dual antiplatelet therapy (aspirin 75-100 mg plus clopidogrel 75 mg daily) without interruption. 1, 2, 3

Antiplatelet Therapy Management - DO NOT INTERRUPT

The most critical consideration is maintaining antiplatelet therapy to prevent catastrophic stent thrombosis:

• Continue aspirin 75-100 mg daily and clopidogrel 75 mg daily without interruption 2, 1
• Premature discontinuation of dual antiplatelet therapy (DAPT) is the most powerful predictor of stent thrombosis, which carries mortality rates up to 20% 1
• For drug-eluting stents, DAPT should continue for at least 6-12 months post-implantation 1, 2
• For bare metal stents, minimum DAPT duration is 4 weeks, though longer is preferred 1

Anti-Inflammatory Treatment Approach

First-Line: Corticosteroids

Systemic corticosteroids are the preferred treatment for pleuritis in stented patients 4:

• Intravenous hydrocortisone initially, followed by oral prednisone 4
• This approach successfully treated post-PCI pleuropericarditis in documented cases 4
• Corticosteroids do not interfere with antiplatelet therapy and avoid cardiovascular risks 4

Avoid NSAIDs - Critical Safety Concern

NSAIDs including ibuprofen are contraindicated or should be strictly avoided 3:

• NSAIDs increase risk of myocardial infarction and stroke, which can be fatal 3
• Post-MI patients treated with NSAIDs show increased risk of reinfarction and CV-related death beginning in the first week of treatment 3
• The incidence of death in the first year post-MI was 20 per 100 person years in NSAID-treated patients versus 12 per 100 person years in non-NSAID exposed patients 3
• NSAIDs should be avoided in patients with recent MI unless benefits clearly outweigh risks 3
• Concurrent use of NSAIDs with aspirin increases risk of serious gastrointestinal bleeding 3

Pleural Drainage if Indicated

If pleural effusion is present with the pleuritis:

• Consider chest tube drainage for symptomatic relief 1
• Saline irrigation (250 mL three times daily) may be used if significant fluid accumulation occurs 1
• For complicated pleural infection, combination tissue plasminogen activator (10 mg twice daily) plus DNase (5 mg twice daily) for 3 days can be considered, though reduced TPA doses (5 mg twice daily) should be used in patients on antiplatelet therapy due to bleeding risk 1

Monitoring Requirements

Close cardiovascular monitoring is essential 5:

• Monitor for changes in anginal pattern (more frequent, severe, or at rest) which could indicate stent thrombosis 5, 6
• The combination of fever and return of angina post-stenting should raise suspicion for stent-related complications including infection 6
• Continuous ECG monitoring if symptoms suggest ischemia 5

Common Pitfalls to Avoid

• Never discontinue antiplatelet therapy to reduce bleeding risk from pleural procedures - stent thrombosis risk far exceeds bleeding risk 1, 7
• Do not use NSAIDs for pain control - cardiovascular risks are unacceptable in this population 3
• Do not assume chest pain is simply pleuritic - always consider stent thrombosis or ischemia in the differential 5, 6
• Avoid bridging with other anticoagulants - this is poorly studied and discouraged 1

Additional Supportive Measures

• Provide sublingual nitroglycerin with clear instructions for any chest symptoms 5
• Continue prescribed antianginal medications throughout treatment 5
• Add proton pump inhibitor for gastrointestinal protection while on DAPT, though avoid omeprazole/esomeprazole which inhibit clopidogrel metabolism 2