Dressler's Syndrome

This is classically a post-myocardial infarction syndrome, usually occurring 2 to 5 days after the initial event but it can be delayed for as long as 3 months. There appears to be an immunological reaction that leads to pericarditis. The term Dressler's syndrome is often applied to a similar condition of similar aetiology that occurs after cardiotomy for open-heart surgery and even sometimes after blunt or penetrating trauma to the chest. Postcardiac injury syndrome also has been observed after cardiac surgery, percutaneous intervention, pacemaker implantation, and radiofrequency ablation.¹

Autopsy shows localised fibrinous pericarditis. It is thought that the condition is immunologically mediated and antiheart antibodies may be found.

The original paper by Dressler in 1956² suggested an incidence of 3 to 4% of all cases of acute myocardial infarction but it is now much rarer at around 4 in 100,000 cases, according to the British Heart Foundation. This is thought to be due to modern methods of management.³ One reason may be that active intervention reduces the size of the infarct.⁴ Some have argued that the syndrome has not vanished but never really existed as a separate entity.⁵

If a person has had a previous episode, it is more likely to recur. It seems more likely to occur after a large infarct.

• It usually presents 3 to 5 days after the initial episode with pain and fever that may suggest further infarction.
• The pain is the main symptom, often in the left shoulder, often pleuritic, and worse on lying down.
• There may be malaise, fever and dyspnoea.
• Rarely, it may cause cardiac tamponade or acute pneumonitis.
• A pericardial friction rub may be heard. The typical sound of pericarditis is described as like the sound of boots walking over fresh snow.

The pain may initially suggest a further episode of angina or MI. Pleuritic chest pain may also suggest pneumonia or pulmonary embolism.

• FBC will show leucocytosis, sometimes with eosinophilia and an elevated ESR.
• Serology may show heart autoantibodies.
• ECG may show ST elevation in most leads without reciprocal ST depression, typical of pericardial effusion.
• Echocardiography shows pericardial effusion.
• MRI scan may show an effusion.
• Chest x-ray shows pleural effusions in 83%, parenchymal opacities in 74%, and an enlarged cardiac silhouette in 49%.

• Aspirin may be given in large doses.
• Other NSAIDs or corticosteroids may be used, especially if there are severe and recurrent symptoms.
• Steroids are particularly valuable where severe symptoms have required pericardiocentesis, and when infection has been excluded.
• In resistant or recurrent cases, colchicine may be useful.
• If there is significant pericardial effusion then pericardiocentesis, involving aspiration of the fluid, may be required to relieve the constriction on the heart.

• Pleuritic pain may be associated with pleurisy and pleural effusion.
• Significant pericardial effusion can cause cardiac tamponade.
• Inflammation can result in constrictive pericarditis.

It can follow a relapsing course but the outcome is usually favourable.

It is likely that modern techniques that involve the use of anti-inflammatory drugs such as aspirin have helped to reduce the incidence of this syndrome.³ Prophylactic use of steroids before cardiac surgery offers no benefit.¹