Management of Post-Cardiac Injury Syndrome (PCIS)
Post-cardiac injury syndrome following percutaneous coronary intervention should be treated with anti-inflammatory therapy, specifically NSAIDs or colchicine as first-line agents, with corticosteroids reserved for refractory cases, while maintaining dual antiplatelet therapy (DAPT) unless bleeding risk is prohibitive. 1
Understanding PCIS After PCI
PCIS is an immune-mediated inflammatory syndrome characterized by pericardial and/or pleural effusion that occurs following cardiac injury, including percutaneous coronary interventions. 1 The syndrome is triggered by immune complex deposition in the pericardium and pleura, causing an inflammatory response with typical features including:
- Fever and elevated inflammatory markers (CRP, ESR, leukocytosis) 1
- Pericardial and/or pleural effusion 1
- Latency period of days to weeks after the procedure 1
- Remarkable responsiveness to corticosteroids 1
Antiplatelet Management During PCIS Treatment
Continue DAPT as Default Strategy
Dual antiplatelet therapy with aspirin 81 mg daily plus a P2Y12 inhibitor (ticagrelor 90 mg twice daily or prasugrel 10 mg daily preferred over clopidogrel 75 mg daily) should be continued for at least 12 months after PCI, even during PCIS treatment. 2
- After PCI for acute coronary syndromes, DAPT must continue for minimum 12 months regardless of stent type 2
- For non-ACS indications with drug-eluting stents, DAPT should continue for at least 12 months if bleeding risk is not prohibitive 2
- Aspirin 81 mg daily is preferred over higher doses to minimize bleeding risk 2
Modification for High Bleeding Risk
If PCIS is complicated by significant pericardial effusion with bleeding risk:
- Consider shortening DAPT duration to <12 months only if bleeding morbidity clearly outweighs ischemic benefit 2
- Transition to ticagrelor monotherapy ≥1 month after PCI is reasonable in patients who have tolerated initial DAPT 2
- Add proton pump inhibitor (avoid omeprazole/esomeprazole with clopidogrel due to CYP2C19 interaction) for gastrointestinal protection 2, 3
Anti-Inflammatory Treatment Protocol
First-Line Therapy
NSAIDs or colchicine should be initiated as first-line anti-inflammatory agents:
- NSAIDs can be used cautiously alongside DAPT, monitoring closely for bleeding complications 1
- Colchicine is an alternative first-line option with potentially lower bleeding risk
- Monitor inflammatory markers (CRP, ESR) and clinical symptoms to assess response 1
Second-Line Therapy for Refractory Cases
Corticosteroids should be reserved for patients who fail to respond to NSAIDs or colchicine: 1
- PCIS demonstrates remarkable steroid responsiveness 1
- Use lowest effective dose and taper gradually to prevent recurrence
- Be aware that corticosteroids may increase bleeding risk when combined with DAPT
Monitoring and Complications
Clinical Surveillance
Monitor for:
- Hemodynamic compromise from pericardial effusion (consider echocardiography)
- Signs of cardiac tamponade requiring urgent pericardiocentesis
- Bleeding complications (hematemesis, melena, hematuria, excessive bruising) from combination of anti-inflammatory therapy and DAPT 4
- Complete blood count to detect occult bleeding manifesting as anemia 4
Critical Pitfall to Avoid
Do not discontinue DAPT prematurely due to PCIS diagnosis, as stent thrombosis risk (leading to MI, cardiogenic shock, and death) far outweighs the bleeding risk in most cases. 3 The risk of stent thrombosis is highest within the first 30 days after stent placement and remains elevated throughout the first year, particularly with drug-eluting stents. 3
Special Considerations
- Atypical presentations may occur, such as hydropneumothorax requiring pleural drainage 1
- PCIS is increasingly recognized as an emerging cause of pericarditis in developed countries due to rising numbers of complex percutaneous procedures 1
- The latency period between PCI and PCIS onset can range from days to weeks (in reported cases, 30-75 days post-procedure) 1