Description

This is classically a postmyocardial 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, radiofrequency ablation and pulmonary vein isolation.^1,2

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

Epidemiology

The original paper by Dressler in 1956³ suggested an incidence of 3-4% of all cases of acute myocardial infarction (MI) 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.⁴ One reason may be that active intervention reduces the size of the infarct.⁵ Some have argued that the syndrome has not vanished but never really existed as a separate entity.⁶

Risk factors

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

Presentation

• 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.

Differential diagnosis

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

Investigations

• 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 and, more recently, has been shown to reveal pericardial involvement.⁷
• Chest X-ray shows pleural effusions in 83%, parenchymal opacities in 74%, and an enlarged cardiac silhouette in 49%.

Management

• Aspirin may be given in large doses.
• Other non-steroidal anti-inflammatory drugs 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.

Complications

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

Prognosis

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

Prevention

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.⁴ Prophylactic use of steroids before cardiac surgery offers no benefit.¹

Document references

1. Wessman DE, Stafford CM; The postcardiac injury syndrome: case report and review of the literature.; South Med J. 2006 Mar;99(3):309-14. [abstract]
2. Luckie M, Jenkins NP, Davidson NC, et al; Dressler's syndrome following pulmonary vein isolation for atrial fibrillation. Acute Card Care. 2008;10(4):234-5. [abstract]
3. Dressler W; A post-myocardial infarction syndrome; preliminary report of a complication resembling idiopathic, recurrent, benign pericarditis.; J Am Med Assoc. 1956 Apr 21;160(16):1379-83.
4. Pasotti M, Prati F, Arbustini E; The pathology of myocardial infarction in the pre and post interventional era.; Heart. 2006 Apr 18;. [abstract]
5. Bendjelid K, Pugin J; Is Dressler syndrome dead?; Chest. 2004 Nov;126(5):1680-2. [abstract]
6. Kossowsky WA, Lyon AF; The postmyocardial infarction syndrome--vanished or vanquished? A twenty-five-year follow-up. A case report.; Angiology. 1996 Jan;47(1):83-5. [abstract]
7. Steadman CD, Khoo J, Kovac J, et al; Dressler's syndrome demonstrated by late gadolinium enhancement cardiovascular J Cardiovasc Magn Reson. 2009 Jul 23;11(1):23. [abstract]

Acknowledgements