Dressler's syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Abdelrahman Ibrahim Abushouk, MD[2]; Mohammed A. Sbeih, M.D.[3]; Cafer Zorkun, M.D., Ph.D. [4]; Nabeel Ahmed, M.B.B.S

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Synonyms and Keywords: Postmyocardial infarction syndrome; PMIS; Post-cardiac injury syndrome

Overview

Dressler's syndrome or post-myocardial infarction syndrome is a form of pericarditis that occurs in the setting of myocardial infarction. It typically occurs 2 to 10 weeks after myocardial infarction. Dressler's syndrome results from an autoimmune inflammatory reaction to myocardial neo-antigens. Possible complications include pericardial effusion, cardiac tamponade, and constrictive pericarditis; however, the prognosis is usually favorable with early treatment. The diagnostic criteria of Dressler's syndrome depend on pleuritic chest pain, pericardial friction rub, ECG changes, and echocardiography-detected pericardial effusion. The recommended medical treatments include aspirin and colchicine.

Historical Perspective

  • Dressler's syndrome was first characterized by William Dressler in 1956.
  • It should not be confused with the Dressler's syndrome of hemoglobinuria, named after Lucas Dressler who characterized it in 1854.[1][2][3]

Classification

  • There is no established system for the classification of Dressler's syndrome.

Pathophysiology

Gross Pathology

Gross pathological examination may show the following findings: [6]

The epicardium was characterized by a fine granular layer on its surface with a “bread and butter” appearance, particularly at the level of the atrial regions and the cardiac apex in a case of Dressler's syndrome. [7]


Microscopic Pathology

Microscopic examination of the myocardial tissue sections may show: [8]

Causes

The common causes of Dressler's syndrome include: [9]

Differentiating Dressler's Syndrome from other Diseases

  • Dressler's syndrome typically occurs 2 to 10 weeks after a myocardial infarction has occurred.[10][11]
  • This differentiates Dressler's syndrome from:
  • Dressler's syndrome should be differentiated from:

Epidemiology and Demographics

  • Incidence: In the setting of myocardial infarction, Dressler's syndrome was classically reported to occur in about 3 to 4% of MI cases.[12]
  • However, the incidence has markedly decreased in the reperfusion era (between 0.5 to 2%), presumably because of smaller infarct sizes.[13]
  • Age: Dressler's syndrome occurs more often in younger age groups.
  • Gender: There is no gender predilection for Dressler's syndrome.
  • Race: There is no racial predilection for Dressler's syndrome.
  • Mortality rate: The prognosis is usually favorable with early treatment with a low mortality rate.

Risk Factors

  • The risk of Dressler's syndrome increases with the size of the infarction.
  • Further, a former episode of Dressler's syndrome increases the risk of relapse upon recurrent MI (the most important risk factor).
  • Epidemiological studies showed a higher risk ratio of Dressler's syndrome with: [14]

Screening

  • There is insufficient evidence to recommend routine screening for Dressler's syndrome.

Natural History, Complications, and Prognosis

Natural History

Complications

The complications of Dressler's syndrome may include: [16]

Prognosis

Diagnosis

Diagnostic Study of Choice

"2017 Revised ESC Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)

Diagnostic criteria do not differ from those for acute pericarditis including two of the following criteria: (i) pleuritic chest pain (85–90% of cases); (ii) pericardial friction rub (≤ 33% of cases); (iii) ECG changes (≤ 60% of cases), with new widespread ST-segment elevation, usually mild and progressive, or PR depression in the acute phase; and (iv) pericardial effusion (≤ 60% of cases and generally mild)".[17]

History and Symptoms

The syndrome consists of a persistent low-grade fever and chest pain which is usually pleuritic in nature.The symptoms enlisted below tend to occur after a few weeks or even months after myocardial infarction and tend to subside in a few days: [18]

Physical Examination

Physical examination of patients with Dressler's syndrome may show[16]:

Laboratory Findings

The laboratory work-up of patients with Dressler's syndrome may include: [16]

Electrocardiogram

An ECG may demonstrate: [19]

Widespread concave ST elevation and PR depression is present throughout the precordial (V2-6) and limb leads (I, II, aVL, aVF). Case Courtesy of Ed Burns [20]


X-ray

The findings of chest x-ray in Dressler's syndrome may include: [21]

  • Enlargement of the cardiac silhouette (non-specific chamber enlargement).

Echocardiography or Ultrasound

CT scan

The findings of CT scan in Dressler's syndrome may include: [23]

MRI

The findings of MRI in Dressler's syndrome may include:

Other Imaging Findings

There are no other imaging findings associated with Dressler's syndrome.

Other Diagnostic Studies

There are no other diagnostic studies associated with Dressler's syndrome.

Treatment

Medical Therapy

Dressler's syndrome is typically treated with high dose (up to 650 mg PO q 4 to 6 hours) enteric-coated aspirin. Acetaminophen can be added for pain management as this does not affect the coagulation system. Anticoagulants should be discontinued if the patient develops a pericardial effusion.[26]

"2017 Revised ESC Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)

  • Anti-inflammatory therapy is recommended in post-STEMI pericarditis as in post-cardiac injury pericardial syndromes for symptom relief and reduction of recurrences.
  • Aspirin is recommended as first choice of anti-inflammatory therapy post-STEMI at a dose of 500–1000 mg every 6–8 h for 1–2 weeks, decreasing the total daily dose by 250–500 mg every 1–2 weeks in keeping with 2015 ESC Guidelines for the diagnosis and management of pericardial diseases.
  • Colchicine is recommended as first-line therapy as an adjunct to aspirin/non-steroidal anti-inflammatory drug therapy (3 months) and is also recommended for the recurrent forms (6 months).
  • Corticosteroids are not recommended due to the risk of scar thinning with aneurysm development or rupture.
  • Pericardiocentesis is rarely required, except for cases of haemodynamic compromise with signs of tamponade".[27]

2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction

Management of Pericarditis After STEMI

Class I
"1. Aspirin is recommended for treatment of pericarditis after STEMI.(Level of Evidence: B)"
Class III (Harm)
"1. Glucocorticoids and nonsteroidal antiinflammatory drugs are potentially harmful for treatment of pericarditis after STEMI. (Level of Evidence: B)"
Class IIb
"1. Administration of acetaminophen, colchicine, or narcotic analgesics may be reasonable if aspirin, even in higher doses, is not effective. (Level of Evidence: B)"

Surgery

  • No surgical intervention is recommended in the management of Dressler's syndrome.
  • Pericardiocentesis is rarely required, except for cases of hemodynamic compromise with signs of tamponade[16].

Primary Prevention

Despite the lack of guidelines on the prevention of Dressler's syndrome, MI patients with the aforementioned risk factors should be followed closely in the few weeks after the ischemic event for the early detection of signs of pericarditis.

Secondary Prevention

  • Recurrence of Dressler's syndrome is common and relapses were reported up to 1 year following the event.
  • Some researchers suggest that intravenous immunoglobulin therapy has some benefit in resistant cases.[28]


References

  1. synd/3982 at Who Named It
  2. L. A. Dressler. Ein Fall von intermittirender Albuminurie und Chromaturie. Archiv für pathologische Anatomie und Physiologie und für klinische Medicin, 1854, 6: 264-266.
  3. DRESSLER W (1956). "A post-myocardial infarction syndrome; preliminary report of a complication resembling idiopathic, recurrent, benign pericarditis". J Am Med Assoc. 160 (16): 1379–83. PMID 13306560.
  4. Engle MA, Zabriskie JB, Senterfit LB (1976). "Heart-reactive antibody, viral illness, and the postpericardiotomy syndrome. Correlates of a triple-blind, prospective study". Trans Am Clin Climatol Assoc. 87: 147–60. PMC 2441394. PMID 785768.
  5. Jerjes-Sánchez C, Ramírez-Rivera A, Ibarra-Pérez C (1996). "The Dressler syndrome after pulmonary embolism". Am J Cardiol. 78 (3): 343–5. PMID 8759817.
  6. Feola A, De Stefano N, Della Pietra B (2015). "Pericarditis Epistenocardica or Dressler Syndrome? An Autopsy Case". Case Rep Med. 2015: 215340. doi:10.1155/2015/215340. PMC 4512600. PMID 26240567.
  7. https://www.hindawi.com/journals/crim/2015/215340/fig1//
  8. Feola A, De Stefano N, Della Pietra B (2015). "Pericarditis Epistenocardica or Dressler Syndrome? An Autopsy Case". Case Rep Med. 2015: 215340. doi:10.1155/2015/215340. PMC 4512600. PMID 26240567.
  9. "StatPearls". 2019. PMID 28723017.
  10. 10.0 10.1 Krainin F, Flessas A, Spodick D (1984). "Infarction-associated pericarditis. Rarity of diagnostic electrocardiogram". N Engl J Med. 311 (19): 1211–4. PMID 6493274.
  11. Krainin F, Flessas A, Spodick D (1984). "Infarction-associated pericarditis. Rarity of diagnostic electrocardiogram". N Engl J Med. 311 (19): 1211–4. PMID 6493274.
  12. Krainin F, Flessas A, Spodick D (1984). "Infarction-associated pericarditis. Rarity of diagnostic electrocardiogram". N Engl J Med. 311 (19): 1211–4. PMID 6493274.
  13. Tofler GH, Muller JE, Stone PH, Willich SN, Davis VG, Poole WK; et al. (1989). "Pericarditis in acute myocardial infarction: characterization and clinical significance". Am Heart J. 117 (1): 86–92. PMID 2643287.
  14. "StatPearls". 2019. PMID 28723017.
  15. Engle MA, Zabriskie JB, Senterfit LB (1976). "Heart-reactive antibody, viral illness, and the postpericardiotomy syndrome. Correlates of a triple-blind, prospective study". Trans Am Clin Climatol Assoc. 87: 147–60. PMC 2441394. PMID 785768.
  16. 16.0 16.1 16.2 16.3 "StatPearls". 2019. PMID 28723017.
  17. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H; et al. (2018). "2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)". Eur Heart J. 39 (2): 119–177. doi:10.1093/eurheartj/ehx393. PMID 28886621.
  18. Wessman DE, Stafford CM (2006). "The postcardiac injury syndrome: case report and review of the literature". South Med J. 99 (3): 309–14. doi:10.1097/01.smj.0000203330.15503.0b. PMID 16553111.
  19. Hendry C, Liew CK, Chauhan A, Zacharias J (2012). "A life-saving case of Dressler's syndrome". Eur Heart J Acute Cardiovasc Care. 1 (3): 232–5. doi:10.1177/2048872612452319. PMC 3760538. PMID 24062911.
  20. https://litfl.com/wp-content/uploads/2018/08/ECG-Pericarditis.jpg
  21. Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK (June 2010). "Pericardial disease: diagnosis and management". Mayo Clin. Proc. 85 (6): 572–93. doi:10.4065/mcp.2010.0046. PMC 2878263. PMID 20511488.
  22. Wessman DE, Stafford CM (March 2006). "The postcardiac injury syndrome: case report and review of the literature". South. Med. J. 99 (3): 309–14. doi:10.1097/01.smj.0000203330.15503.0b. PMID 16553111.
  23. Levin EJ, Bryk D (1966). "Dressler syndrome (postmyocardial infarction syndrome)". Radiology. 87 (4): 731–6. doi:10.1148/87.4.731. PMID 5923769.
  24. Scarfone RJ, Donoghue AJ, Alessandrini EA (August 2003). "Cardiac tamponade complicating postpericardiotomy syndrome". Pediatr Emerg Care. 19 (4): 268–71. doi:10.1097/01.pec.0000092573.40174.74. PMID 12972828.
  25. Steadman CD, Khoo J, Kovac J, McCann GP (2009). "Dressler's syndrome demonstrated by late gadolinium enhancement cardiovascular magnetic resonance". J Cardiovasc Magn Reson. 11: 23. doi:10.1186/1532-429X-11-23. PMC 2723097. PMID 19627595.
  26. Jaworska-Wilczynska M, Abramczuk E, Hryniewiecki T (November 2011). "Postcardiac injury syndrome". Med. Sci. Monit. 17 (11): CQ13–14. doi:10.12659/msm.882029. PMID 22037738.
  27. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H; et al. (2018). "2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)". Eur Heart J. 39 (2): 119–177. doi:10.1093/eurheartj/ehx393. PMID 28886621.
  28. del Fresno MR, Peralta JE, Granados MÁ, Enríquez E, Domínguez-Pinilla N, de Inocencio J (2014). "Intravenous immunoglobulin therapy for refractory recurrent pericarditis". Pediatrics. 134 (5): e1441–6. doi:10.1542/peds.2013-3900. PMID 25287461.

See also


de:Dressler-Syndrom