Post-Cardiac Injury Syndrome following Percutaneous Coronary Intervention: A Rare Case Report

Post-Cardiac Injury Syndrome following Percutaneous Coronary Intervention: A Rare Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Post-Cardiac Injury Syndrome following Percutaneous Coronary Intervention: A Rare Case Report Ashok Victor, Panneer Selvam Ganesan, Manikandan Rajendran, Nihal Sheriff This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6074644/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Post-Cardiac Injury Syndrome (PCIS) is a rare inflammatory condition following cardiac interventions like PCI, characterized by pleuritic chest pain, fever, pericardial effusion, and ECG changes. Its pathophysiology involves autoimmune responses or micro-extravasation. Though rare (< 0.5% incidence post-PCI), early recognition and treatment are crucial to prevent complications. Case Presentation: A 69-year-old male with unstable angina underwent an unsuccessful PCI for mid-LAD CTO. Eight hours later, he developed pleuritic chest pain and low-grade fever. ECG showed widespread ST-elevations with PR-segment depression, and echocardiography revealed mild pericardial effusion. Inflammatory markers were elevated, but cardiac troponin I remained negative. Despite no visible extravasation on fluoroscopy, micro-extravasation was suspected. A diagnosis of iatrogenic PCIS was made, and he was treated with high-dose aspirin, leading to symptom resolution by day five. Conclusions: This case underscores the importance of recognizing PCIS post-PCI, even in the absence of visible extravasation. Early diagnosis through clinical signs, ECG, and inflammatory markers enables prompt treatment with NSAIDs, primarily aspirin. With appropriate management, outcomes are favorable, though monitoring for recurrence and long-term complications like constrictive pericarditis remains essential. PCI complication post-cardiac injury syndrome pericarditis Figures Figure 1 Figure 2 Figure 3 Background Post-Cardiac Injury Syndrome (PCIS) is a rare but important inflammatory complication following cardiac interventions, including percutaneous coronary intervention (PCI) (1) . It is characterized by pleuritic chest pain, fever, ECG changes, pericardial effusion, and elevated inflammatory markers. The pathophysiology is thought to involve autoimmune responses triggered by pericardial injury or extravasation of blood. Although the incidence of PCIS after PCI is low (< 0.5%), its timely recognition and management are crucial to prevent complications such as recurrent pericarditis or constrictive pericarditis (2) . This case report presents a 69-year-old male who developed iatrogenic PCIS after an unsuccessful PCI for mid-left anterior descending artery (LAD) chronic total occlusion (CTO). Despite no visible extravasation, pericardial inflammation developed post-procedure. The aim of this report is to emphasize the need for early diagnosis and appropriate management of PCIS using NSAIDs, particularly aspirin, to ensure favorable patient outcomes and minimize long-term complications. Case presentation A 69-year-old male presented with complaints of typical anginal chest pain for the past six hours associated with nausea and vomiting. His past history was significant for anginal chest pain and hypertension for the past four years. He had no history of any previous coronary interventions. On examination, he was obese, vitals were stable and his systemic examination was within normal limits. His initial presenting 12-lead electrocardiogram (ECG) revealed biphasic T-waves in V 3 and V 4 , T-wave inversions in leads V 5 , V 6 and in leads I and aVL ( Fig. 1 ) . His echocardiogram revealed no regional wall motion abnormalities and a normal left ventricular systolic function. Cardiac troponin I (CTnI) was negative when measured at 0, 1-hr and at 6-hrs after presentation. His routine blood examinations were also normal. He was diagnosed to have Acute Coronary Syndrome – Unstable Angina. The patient was taken up for coronary angiogram the following day which revealed CTO of mid-LAD with heterocollaterals filling from right coronary artery (RCA) leading to visualisation of the distal LAD. The distal left circumflex and proximal to mid RCA also were diffusely diseased although they were not hemodynamically significant ( Fig. 2 , Videos 1 and 2 – Coronary angiogram revealing chronic total occlusion of left anterior descending artery) . A PCI was attempted unsuccessfully through the anterograde technique as two different wires (Cross IT and Whisper) could not cross the lesion (Video 3 – Attempted percutaneous coronary intervention of the lesion) . The procedure was abandoned and he was planned for a PCI on a later date. The procedure was uneventful and there was no contrast extravasation on check angiograms. Eight hours after the procedure, the patient developed a pleuritic type of mild chest pain and one episode of low-grade fever that responded to paracetamol. His vitals were stable. A repeat ECG revealed diffuse widespread ST-elevation in the precordial and limb leads with PR-segment depression, with ST-depression and PR-segment elevation in lead aVR ( Fig. 3 ) . CTnI was repeated and found to be negative while erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated. Repeat echocardiogram revealed a mild circumferential pericardial effusion with no regional wall motion abnormalities (Video 4 – Echocardiogram revealing mild circumferential pericardial effusion) . Based on the above findings, a diagnosis of iatrogenic PCIS was made and the patient was treated with 450mg aspirin three times a day. By the fifth day, the ECG had settled down and the patient was discharged with optimal medical management with a plan for a PCI to LAD at a later stage. The high dose aspirin was down-titrated over 2 weeks. Discussion Pericarditis associated with pericardial effusion, that occurs as a result of an injury to the pericardium is known as PCIS. It comprises of three conditions, post-myocardial infarction (MI) associated pericarditis, post-pericardiotomy syndrome (PPS) and post-traumatic pericarditis (1) . The incidence of pericardial complications post-PCI has been reported to be < 0.5% and less than 1–5% for other cardiac interventions (2) . The diagnostic criteria for PCIS requires the presence of two of the following five criteria: (i) fever without alternative cause, (ii) pericarditic or pleuritic chest pain, (iii) pericardial or pleural rubs, (iv) evidence of pericardial effusion and/or (v) pleural effusion with elevated CRP (3) . In our case we met three of the five criteria. The current hypothesis for the pathophysiology of PCIS directs towards autoimmunity with the cascade being initiated with damage to pericardial or pleural mesothelial cells, which is supported by the detection of anti-actin and anti-myosin antibodies along with a latency period for the presentation of PCIS lasting from weeks to months (4,5) . Another mechanism is due to extravasation of blood into the pericardium which can irritate the visceral layer of pericardium and cause inflammation as has been reported in a few cases of PCIS following PCI as a result of coronary perforation or dissection (6–8) . In our case there was no visible extravasation on fluoroscopy. It can be assumed that there was micro-extravasation due to the prolonged wiring in the CTO of LAD, which released inflammatory cytokines and resulted in the pericardial effusion as has been noted in another similar case (9) . The presentation of a patient with PCIS includes pleuritic chest pain, dyspnoea, low-grade fever, elevated markers of inflammation and pericardial effusion which is usually mild. A pericardial rub may be heard in 30–60% of cases while ECG changes of widespread ST-elevation and PR segment depression may be seen in another 20%. Chest x-ray may reveal a pleural effusion (1) . The management of PCIS typically involves the usage of non-steroidal anti-inflammatory agents (NSAIDS) as a first line, with aspirin being preferred in cases with concomitant coronary artery disease due to its anti-platelet effect. The recommended doses are 750-1000mg q8h for aspirin while indomethacin is given at 600mg q8h until the inflammatory markers return to baseline with careful down-titration over two weeks. Colchicine and steroids are second line agents when there is contraindication to NSAIDs or recurrence/ resistant pericarditis (1) . Prognosis is generally good for these patients with a recurrence rate of 10–15% and a risk of developing constrictive pericarditis in 2% (1,10) . Conclusion This case highlights the importance of recognizing Post-Cardiac Injury Syndrome (PCIS) as a rare but significant complication following PCI, even in the absence of visible extravasation. Early identification through clinical symptoms, ECG changes, and inflammatory markers is essential for prompt treatment. High-dose aspirin remains the first-line therapy, ensuring symptom resolution and reducing recurrence risk. While prognosis is generally favorable, careful monitoring is required to prevent long-term complications such as constrictive pericarditis. This case emphasizes the need for vigilance in post-PCI patients to ensure timely diagnosis, appropriate management, and optimal patient outcomes. Abbreviations CRP C–reactive protein CTnI Cardiac troponin I CTO chronic total occlusion ECG Electrocardiogram ESR erythrocyte sedimentation rate LAD left anterior descending artery MI myocardial infarction NSAID Non–steroidal anti–inflammatory drugs PCI percutaneous coronary intervention PCIS post–cardiac injury syndrome PPS post–pericardiotomy syndrome RCA right coronary artery Declarations Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethics approval and Informed consent Since it is a case report, ethics approval was not necessary. Informed consent obtained from the patient. Consent for publication Received from the patient Author Contribution Nihal Sheriff was involved with data collection and writing the original draft. Manikandan Rajendran and Panneer Selvam Ganesan were involved in data collection, draft editing and investigation of the case. Ashok Victor was involved in supervision, concept design and critical revision of the final version of the draft. All authors reviewed the manuscript. References Imazio M, Hoit BD. Post-cardiac injury syndromes. An emerging cause of pericardial diseases. Int J Cardiol. 2013 Sep 30;168(2):648-52. Malik J, Zaidi SMJ, Rana AS, Haider A, Tahir S. Post-cardiac injury syndrome: An evidence-based approach to diagnosis and treatment. Am Heart J Plus. 2021 Nov 19;12:100068. doi: 10.1016/j.ahjo.2021.100068. PMID: 38559602; PMCID: PMC10978175. Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristić AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W. 2015 ESC Guidelines for the Diagnosis and Management of Pericardial Diseases. Rev Esp Cardiol (Engl Ed). 2015 Dec;68(12):1126. doi: 10.1016/j.rec.2015.10.008. PMID: 26675200. A. Barosi, C. Simon, P. Ferrazzi, R. Belli, R. Trinchero, D. Spodick, Y. Adler, Contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome, Am. J. Cardiol. 108 (8) (2011) 1183–1187. I. De Scheerder, M. De Buyzere, J. Robbrecht, M. De Lange, J. Delanghe, A. M. Bogaert, D. Clement, Postoperative immunological response against contractile proteins after coronary bypass surgery, Br. Heart J. 56 (5) (1986) 440–444. Escaned, J.; Ahmad, R.A.; Shiu, M.F. Pleural effusion following coronary perforation during balloon angioplasty: An unusual presentation of the postpericardiotomy syndrome. Eur. Heart J. 1992 , 13, 716–717. Hung, M.-J.; Kuo, L.-T.; Cherng,W.-J. Acute pericarditis following percutaneous transluminal coronary intervention—A case report. Angiology 2003 , 54, 503–506. Yang, K.-P.; Yu, W.-C.; Lu, T.-M. Acute pericarditis after percutaneous coronary intervention mimicking inferolateral ST-elevation myocardial infarction. J. Invasive Cardiol. 2013 , 25, E27–E29 Rodevič G, Budrys P, Davidavičius G. Acute Pericarditis after Percutaneous Coronary Intervention: A Case Report. Medicina (Kaunas). 2021 May 13;57(5):490. doi: 10.3390/medicina57050490. PMID: 34067941; PMCID: PMC8152033. F. Sabzi, R. Faraji, Predictors of post pericardiotomy low cardiac output syndrome in patients with pericardial effusion, J. Cardiovasc. Thorac. Res. 7 (1) (2015) 18–23. Additional Declarations No competing interests reported. Supplementary Files Video1.mp4 Video2.mp4 Video3.mp4 Video4.wmv Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6074644","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":420305492,"identity":"73d85756-256f-4d3f-807f-48ba51a28532","order_by":0,"name":"Ashok Victor","email":"","orcid":"","institution":"Madras Medical College","correspondingAuthor":false,"prefix":"","firstName":"Ashok","middleName":"","lastName":"Victor","suffix":""},{"id":420305493,"identity":"b5dbec73-765f-482c-9173-2da53b2d9145","order_by":1,"name":"Panneer Selvam Ganesan","email":"","orcid":"","institution":"Madras Medical College","correspondingAuthor":false,"prefix":"","firstName":"Panneer","middleName":"Selvam","lastName":"Ganesan","suffix":""},{"id":420305494,"identity":"41739963-2c8b-466e-8222-cd02b9fb04f0","order_by":2,"name":"Manikandan Rajendran","email":"","orcid":"","institution":"Madras Medical College","correspondingAuthor":false,"prefix":"","firstName":"Manikandan","middleName":"","lastName":"Rajendran","suffix":""},{"id":420305495,"identity":"a0136f66-b1ba-4db5-b54e-8292d808da70","order_by":3,"name":"Nihal Sheriff","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYDACCRBhcICBj70BxLAgQQsbzwEQQ4JYLQxALRIJCC5eID+7+djngoI78mySz69u+FEgwcDf3p2AV4vBnWPJs2cYPDNsk84pu9kDdJjEmbMb8GuRyDFm5jE4zAjUknaDB6jFQCIXvxb5GfmfQVrs2yTPpN38Q4wWhhs5zCAtiW0S7MduE2WLwY00sMOS23hy2G7LGEjwEPSL/Izkx8w8fw7b9rMff3bzzR8bOf72XgIOQwAeAzBJrHIQYH9AiupRMApGwSgYQQAAGBdDleUSOJAAAAAASUVORK5CYII=","orcid":"","institution":"Madras Medical College","correspondingAuthor":true,"prefix":"","firstName":"Nihal","middleName":"","lastName":"Sheriff","suffix":""}],"badges":[],"createdAt":"2025-02-20 20:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6074644/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6074644/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":77616912,"identity":"bcb86541-a9ed-4aac-9a3c-88f627b4d87c","added_by":"auto","created_at":"2025-03-03 15:06:40","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":107575,"visible":true,"origin":"","legend":"\u003cp\u003eElectrocardiogram at presentation revealing biphasic T-waves in V\u003csub\u003e3\u003c/sub\u003e and V\u003csub\u003e4\u003c/sub\u003e, T-wave inversions in leads V\u003csub\u003e5\u003c/sub\u003e, V\u003csub\u003e6 \u003c/sub\u003eand in leads I and aVL\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6074644/v1/414cdbfd0dd94f470f2c0989.jpg"},{"id":77618726,"identity":"1fc3e157-6a3e-466b-a779-782a6f628523","added_by":"auto","created_at":"2025-03-03 15:22:40","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":205967,"visible":true,"origin":"","legend":"\u003cp\u003ea. Left coronary injection revealing chronic total occlusion of left anterior descending artery, b. Right coronary injection revealing retrogradely filling left anterior descending artery.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6074644/v1/42128d38e250283946e45602.jpg"},{"id":77618338,"identity":"15742917-ed0f-4168-b893-b56059686c44","added_by":"auto","created_at":"2025-03-03 15:14:40","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":112928,"visible":true,"origin":"","legend":"\u003cp\u003eElectrocardiogram revealing diffuse concave ST elevation in precordial and limb leads with PR segment depression and ST depression in aVR, suggestive of pericarditis\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6074644/v1/fc3c47d7094c017f12e35e6b.jpg"},{"id":77620713,"identity":"b922c71c-8339-4374-8fdf-2e3b459702ca","added_by":"auto","created_at":"2025-03-03 15:38:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":906767,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6074644/v1/b82b9627-c169-44ab-9bd0-60f3908b311c.pdf"},{"id":77618335,"identity":"067d4e62-e5c1-4060-ad1a-38682c469757","added_by":"auto","created_at":"2025-03-03 15:14:40","extension":"mp4","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":938233,"visible":true,"origin":"","legend":"","description":"","filename":"Video1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6074644/v1/891311b495bcfc18926132b4.mp4"},{"id":77616902,"identity":"10d4a6c5-f626-47de-9026-a0341ffe4d5e","added_by":"auto","created_at":"2025-03-03 15:06:40","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1249468,"visible":true,"origin":"","legend":"","description":"","filename":"Video2.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6074644/v1/69d05f9949973a2db5492198.mp4"},{"id":77616913,"identity":"415d2534-7b1b-4033-a5fb-9a428f4aa8ed","added_by":"auto","created_at":"2025-03-03 15:06:40","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":823353,"visible":true,"origin":"","legend":"","description":"","filename":"Video3.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6074644/v1/c94856b8953aee7185fb3a7b.mp4"},{"id":77616922,"identity":"bec24c44-6aa8-499e-8ce8-c6f3c2e86076","added_by":"auto","created_at":"2025-03-03 15:06:40","extension":"wmv","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":2253431,"visible":true,"origin":"","legend":"","description":"","filename":"Video4.wmv","url":"https://assets-eu.researchsquare.com/files/rs-6074644/v1/ec39526758f872022ee27b4f.wmv"}],"financialInterests":"No competing interests reported.","formattedTitle":"Post-Cardiac Injury Syndrome following Percutaneous Coronary Intervention: A Rare Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003ePost-Cardiac Injury Syndrome (PCIS) is a rare but important inflammatory complication following cardiac interventions, including percutaneous coronary intervention (PCI) \u003csup\u003e(1)\u003c/sup\u003e. It is characterized by pleuritic chest pain, fever, ECG changes, pericardial effusion, and elevated inflammatory markers. The pathophysiology is thought to involve autoimmune responses triggered by pericardial injury or extravasation of blood. Although the incidence of PCIS after PCI is low (\u0026lt;\u0026thinsp;0.5%), its timely recognition and management are crucial to prevent complications such as recurrent pericarditis or constrictive pericarditis \u003csup\u003e(2)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis case report presents a 69-year-old male who developed iatrogenic PCIS after an unsuccessful PCI for mid-left anterior descending artery (LAD) chronic total occlusion (CTO). Despite no visible extravasation, pericardial inflammation developed post-procedure. The aim of this report is to emphasize the need for early diagnosis and appropriate management of PCIS using NSAIDs, particularly aspirin, to ensure favorable patient outcomes and minimize long-term complications.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 69-year-old male presented with complaints of typical anginal chest pain for the past six hours associated with nausea and vomiting. His past history was significant for anginal chest pain and hypertension for the past four years. He had no history of any previous coronary interventions.\u003c/p\u003e \u003cp\u003eOn examination, he was obese, vitals were stable and his systemic examination was within normal limits. His initial presenting 12-lead electrocardiogram (ECG) revealed biphasic T-waves in V\u003csub\u003e3\u003c/sub\u003e and V\u003csub\u003e4\u003c/sub\u003e, T-wave inversions in leads V\u003csub\u003e5\u003c/sub\u003e, V\u003csub\u003e6\u003c/sub\u003e and in leads I and aVL \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. His echocardiogram revealed no regional wall motion abnormalities and a normal left ventricular systolic function. Cardiac troponin I (CTnI) was negative when measured at 0, 1-hr and at 6-hrs after presentation. His routine blood examinations were also normal. He was diagnosed to have Acute Coronary Syndrome \u0026ndash; Unstable Angina.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient was taken up for coronary angiogram the following day which revealed CTO of mid-LAD with heterocollaterals filling from right coronary artery (RCA) leading to visualisation of the distal LAD. The distal left circumflex and proximal to mid RCA also were diffusely diseased although they were not hemodynamically significant \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003eVideos 1 and 2 \u0026ndash; Coronary angiogram revealing chronic total occlusion of left anterior descending artery)\u003c/b\u003e. A PCI was attempted unsuccessfully through the anterograde technique as two different wires (Cross IT and Whisper) could not cross the lesion \u003cb\u003e(Video 3 \u0026ndash; Attempted percutaneous coronary intervention of the lesion)\u003c/b\u003e. The procedure was abandoned and he was planned for a PCI on a later date. The procedure was uneventful and there was no contrast extravasation on check angiograms.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eEight hours after the procedure, the patient developed a pleuritic type of mild chest pain and one episode of low-grade fever that responded to paracetamol. His vitals were stable. A repeat ECG revealed diffuse widespread ST-elevation in the precordial and limb leads with PR-segment depression, with ST-depression and PR-segment elevation in lead aVR \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. CTnI was repeated and found to be negative while erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated. Repeat echocardiogram revealed a mild circumferential pericardial effusion with no regional wall motion abnormalities \u003cb\u003e(Video 4 \u0026ndash; Echocardiogram revealing mild circumferential pericardial effusion)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBased on the above findings, a diagnosis of iatrogenic PCIS was made and the patient was treated with 450mg aspirin three times a day. By the fifth day, the ECG had settled down and the patient was discharged with optimal medical management with a plan for a PCI to LAD at a later stage. The high dose aspirin was down-titrated over 2 weeks.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePericarditis associated with pericardial effusion, that occurs as a result of an injury to the pericardium is known as PCIS. It comprises of three conditions, post-myocardial infarction (MI) associated pericarditis, post-pericardiotomy syndrome (PPS) and post-traumatic pericarditis \u003csup\u003e(1)\u003c/sup\u003e. The incidence of pericardial complications post-PCI has been reported to be \u0026lt;\u0026thinsp;0.5% and less than 1\u0026ndash;5% for other cardiac interventions \u003csup\u003e(2)\u003c/sup\u003e. The diagnostic criteria for PCIS requires the presence of two of the following five criteria: (i) fever without alternative cause, (ii) pericarditic or pleuritic chest pain, (iii) pericardial or pleural rubs, (iv) evidence of pericardial effusion and/or (v) pleural effusion with elevated CRP \u003csup\u003e(3)\u003c/sup\u003e. In our case we met three of the five criteria.\u003c/p\u003e \u003cp\u003eThe current hypothesis for the pathophysiology of PCIS directs towards autoimmunity with the cascade being initiated with damage to pericardial or pleural mesothelial cells, which is supported by the detection of anti-actin and anti-myosin antibodies along with a latency period for the presentation of PCIS lasting from weeks to months \u003csup\u003e(4,5)\u003c/sup\u003e. Another mechanism is due to extravasation of blood into the pericardium which can irritate the visceral layer of pericardium and cause inflammation as has been reported in a few cases of PCIS following PCI as a result of coronary perforation or dissection \u003csup\u003e(6\u0026ndash;8)\u003c/sup\u003e. In our case there was no visible extravasation on fluoroscopy. It can be assumed that there was micro-extravasation due to the prolonged wiring in the CTO of LAD, which released inflammatory cytokines and resulted in the pericardial effusion as has been noted in another similar case \u003csup\u003e(9)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe presentation of a patient with PCIS includes pleuritic chest pain, dyspnoea, low-grade fever, elevated markers of inflammation and pericardial effusion which is usually mild. A pericardial rub may be heard in 30\u0026ndash;60% of cases while ECG changes of widespread ST-elevation and PR segment depression may be seen in another 20%. Chest x-ray may reveal a pleural effusion \u003csup\u003e(1)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe management of PCIS typically involves the usage of non-steroidal anti-inflammatory agents (NSAIDS) as a first line, with aspirin being preferred in cases with concomitant coronary artery disease due to its anti-platelet effect. The recommended doses are 750-1000mg q8h for aspirin while indomethacin is given at 600mg q8h until the inflammatory markers return to baseline with careful down-titration over two weeks. Colchicine and steroids are second line agents when there is contraindication to NSAIDs or recurrence/ resistant pericarditis \u003csup\u003e(1)\u003c/sup\u003e. Prognosis is generally good for these patients with a recurrence rate of 10\u0026ndash;15% and a risk of developing constrictive pericarditis in 2% \u003csup\u003e(1,10)\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case highlights the importance of recognizing Post-Cardiac Injury Syndrome (PCIS) as a rare but significant complication following PCI, even in the absence of visible extravasation. Early identification through clinical symptoms, ECG changes, and inflammatory markers is essential for prompt treatment. High-dose aspirin remains the first-line therapy, ensuring symptom resolution and reducing recurrence risk. While prognosis is generally favorable, careful monitoring is required to prevent long-term complications such as constrictive pericarditis. This case emphasizes the need for vigilance in post-PCI patients to ensure timely diagnosis, appropriate management, and optimal patient outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eC\u0026ndash;reactive protein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTnI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiac troponin I\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003echronic total occlusion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eECG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eElectrocardiogram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eerythrocyte sedimentation rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eleft anterior descending artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emyocardial infarction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNSAID\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon\u0026ndash;steroidal anti\u0026ndash;inflammatory drugs\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epercutaneous coronary intervention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCIS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epost\u0026ndash;cardiac injury syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epost\u0026ndash;pericardiotomy syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eright coronary artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and Informed consent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSince it is a case report, ethics approval was not necessary. Informed consent obtained from the patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReceived from the patient\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eNihal Sheriff was involved with data collection and writing the original draft. Manikandan Rajendran and Panneer Selvam Ganesan were involved in data collection, draft editing and investigation of the case. Ashok Victor was involved in supervision, concept design and critical revision of the final version of the draft. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eImazio M, Hoit BD. Post-cardiac injury syndromes. An emerging cause of pericardial diseases. Int J Cardiol. 2013 Sep 30;168(2):648-52. \u003c/li\u003e\n\u003cli\u003eMalik J, Zaidi SMJ, Rana AS, Haider A, Tahir S. Post-cardiac injury syndrome: An evidence-based approach to diagnosis and treatment. Am Heart J Plus. 2021 Nov 19;12:100068. doi: 10.1016/j.ahjo.2021.100068. PMID: 38559602; PMCID: PMC10978175.\u003c/li\u003e\n\u003cli\u003eAdler Y, Charron P, Imazio M, Badano L, Bar\u0026oacute;n-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristić AD, Sabat\u0026eacute; Tenas M, Seferovic P, Swedberg K, Tomkowski W. 2015 ESC Guidelines for the Diagnosis and Management of Pericardial Diseases. Rev Esp Cardiol (Engl Ed). 2015 Dec;68(12):1126. doi: 10.1016/j.rec.2015.10.008. PMID: 26675200.\u003c/li\u003e\n\u003cli\u003eA. Barosi, C. Simon, P. Ferrazzi, R. Belli, R. Trinchero, D. Spodick, Y. Adler, Contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome, Am. J. Cardiol. 108 (8) (2011) 1183\u0026ndash;1187.\u003c/li\u003e\n\u003cli\u003eI. De Scheerder, M. De Buyzere, J. Robbrecht, M. De Lange, J. Delanghe, A. M. Bogaert, D. Clement, Postoperative immunological response against contractile proteins after coronary bypass surgery, Br. Heart J. 56 (5) (1986) 440\u0026ndash;444.\u003c/li\u003e\n\u003cli\u003eEscaned, J.; Ahmad, R.A.; Shiu, M.F. Pleural effusion following coronary perforation during balloon angioplasty: An unusual presentation of the postpericardiotomy syndrome. Eur. Heart J. \u003cstrong\u003e1992\u003c/strong\u003e, 13, 716\u0026ndash;717. \u003c/li\u003e\n\u003cli\u003eHung, M.-J.; Kuo, L.-T.; Cherng,W.-J. Acute pericarditis following percutaneous transluminal coronary intervention\u0026mdash;A case report. Angiology \u003cstrong\u003e2003\u003c/strong\u003e, 54, 503\u0026ndash;506. \u003c/li\u003e\n\u003cli\u003eYang, K.-P.; Yu, W.-C.; Lu, T.-M. Acute pericarditis after percutaneous coronary intervention mimicking inferolateral ST-elevation myocardial infarction. J. Invasive Cardiol. \u003cstrong\u003e2013\u003c/strong\u003e, 25, E27\u0026ndash;E29\u003c/li\u003e\n\u003cli\u003eRodevič G, Budrys P, Davidavičius G. Acute Pericarditis after Percutaneous Coronary Intervention: A Case Report. Medicina (Kaunas). 2021 May 13;57(5):490. doi: 10.3390/medicina57050490. PMID: 34067941; PMCID: PMC8152033.\u003c/li\u003e\n\u003cli\u003eF. Sabzi, R. Faraji, Predictors of post pericardiotomy low cardiac output syndrome in patients with pericardial effusion, J. Cardiovasc. Thorac. Res. 7 (1) (2015) 18\u0026ndash;23.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"PCI complication, post-cardiac injury syndrome, pericarditis","lastPublishedDoi":"10.21203/rs.3.rs-6074644/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6074644/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003ePost-Cardiac Injury Syndrome (PCIS) is a rare inflammatory condition following cardiac interventions like PCI, characterized by pleuritic chest pain, fever, pericardial effusion, and ECG changes. Its pathophysiology involves autoimmune responses or micro-extravasation. Though rare (\u0026lt;\u0026thinsp;0.5% incidence post-PCI), early recognition and treatment are crucial to prevent complications.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eA 69-year-old male with unstable angina underwent an unsuccessful PCI for mid-LAD CTO. Eight hours later, he developed pleuritic chest pain and low-grade fever. ECG showed widespread ST-elevations with PR-segment depression, and echocardiography revealed mild pericardial effusion. Inflammatory markers were elevated, but cardiac troponin I remained negative. Despite no visible extravasation on fluoroscopy, micro-extravasation was suspected. A diagnosis of iatrogenic PCIS was made, and he was treated with high-dose aspirin, leading to symptom resolution by day five.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eThis case underscores the importance of recognizing PCIS post-PCI, even in the absence of visible extravasation. Early diagnosis through clinical signs, ECG, and inflammatory markers enables prompt treatment with NSAIDs, primarily aspirin. With appropriate management, outcomes are favorable, though monitoring for recurrence and long-term complications like constrictive pericarditis remains essential.\u003c/p\u003e","manuscriptTitle":"Post-Cardiac Injury Syndrome following Percutaneous Coronary Intervention: A Rare Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-03 15:06:35","doi":"10.21203/rs.3.rs-6074644/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c9c95447-72f2-429e-8d52-906631c0bedc","owner":[],"postedDate":"March 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-03T15:06:37+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-03 15:06:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6074644","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6074644","identity":"rs-6074644","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}