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Dressler Syndrome

Myocardial Postinfarction Syndrome

Dressler syndrome (or postmyocardial infarction syndrome, post cardiac injury syndrome, and post pericardiotomy syndrome) is a complication of pericardial surgery or injury and myocardial infarction, presenting as a form of acute pericarditis. Dressler syndrome presents with low grade fever, pleuritic chest pain, and pericardial friction rub.


Presentation

History

The most constant symptom of dressler syndrome is pleuritic chest pain, typically located retrosternally or on the left precordial region and which is charasteristically relieved by leaning forward and worsened by lying flat [10] [11]. Another common feature of dressler syndrome is fever, which is often low grade [11]. Pneumonitis also occurs sequel to pericardial inflammation.

A history of myocardial infarction, pericardial surgery or injury is required to make a diagnosis of dressler syndrome. A history of risk factors of myocardial infarction should also be sought, these risk factors include obesity, hypertension, family history of ischaemic heart diseases, smoking, and dyslipedemia [10] [11].

Physical examination

Characteristically, on physical examination in dressler syndrome, a pericardial rub is heard on auscultation. This sound results from friction between the inflamed visceral and parietal pericardial layers. The sound is best heard near the end of expiration over the left lower sternal border with the patient leaning forward. Pleural effusion is also a typical finding in dressler syndrome. Another typical finding on physical examination is a dull percussion note in the left upper lung zone and scapular area, this is due to the collapse of the left lung sequel to compression by the enlarged pericardium which results from massive effusion into the pericardial space. This is called Ewart's sign. It is also common to find tachycardia and tachypnea in dressler syndrome.

Pleural Effusion
  • […] silhouette enlargement from pericardial effusion and mild to moderate-sized left (usually) pleural effusion Pleural effusion may be bilateral Pleural effusions (83%) Parenchymal opacities (74%) Enlarged cardiac silhouette from pericardial effusion (49%[learningradiology.com]
  • A small pleural effusion (black arrow) is also visible.[mja.com.au]
  • Dressler's Syndrome:pericarditis after heart attack or open-heart surgery that is often recurrent and is typically accompanied by chest pain, fever, pericardial and pleural effusions, pleurist, lung infiltrates, and joint pain.[echopedia.org]
  •  Symptoms appear 2-3 weeks following infarct/surgery–sometimes years  Chest pain (91%), fever, pericardial and pleural effusion  Also rales, SOB and leukocytosis  Pleural tap: bloody exudate[learningradiology.com]
Pleuritic Pain
  • It consists of fever, pleuritic pain, pericarditis and/or a pericardial effusion. Dressler syndrome is also known as postmyocardial infarction syndrome [1] and the term is sometimes used to refer to post-pericardiotomy pericarditis .[en.wikipedia.org]
  • The symptoms mainly consist of fever, pleuritic pain , pericarditis and pericardial effusion .[xpertdox.com]
  • Complications Pleuritic pain may be associated with pleurisy and pleural effusion . Significant pericardial effusion can cause cardiac tamponade . Inflammation can result in constrictive pericarditis.[patient.info]
  • It consists of fever, pleuritic pain, pericarditis and/or a pericardial effusion. Dressler syndrome is also known as postmyocardial infarction syndrome [ 1 ] and the term is sometimes used to refer to post-pericardiotomy pericarditis .[research.omicsgroup.org]
Fever
  • Little is known about the incidence of fever in the days following pulmonary embolism and such fever could depend on comorbidities.[em-consulte.com]
  • The disease consists of a persistent low-grade fever , chest pain (usually pleuritic in nature), pericarditis (usually evidenced by a pericardial friction rub ), and/or a pericardial effusion .[en.wikipedia.org]
  • Symptoms might include: Chest pain Fever Dressler’s syndrome presents itself in the following manner: It usually presents two to five weeks after the initial episode, with pain and fever that may suggest further infarction.[natural-health-news.com]
  • Dressler's syndrome symptoms include chest pain, much like that experienced during a heart attack, and fever. With recent improvements in heart attack treatments, Dressler's syndrome is less common than it used to be.[sites.google.com]
  • It is characterised by pleuritic chest pain, low-grade fever and pericarditis (autopsy shows localised fibrinous pericarditis), which may be accompanied by pericardial effusion. It tends to follow a benign clinical course.[patient.info]
Malaise
  • ., Ph.D. 1 Citing Article A 57-year-old woman was referred to our clinic because of malaise, dyspnea, and pedal edema four weeks after an extensive myocardial infarction.[nejm.org]
  • Facts : Post myocardial infarction pericarditis Usually occurs weeks after a myocardial infarction History / PE : Malaise, fever Pain worse with deep inspiration, improved by leaning forward Diagnosis : Elevated ESR Diffuse ST segment elevation Treatment[medlibes.com]
  • Dress·ler's syndrome \ ˈdres-lərz- \ Medical Definition of Dressler's syndrome : pericarditis after heart attack or open-heart surgery that is often recurrent and is typically accompanied by chest pain, fever, malaise, difficulty in breathing, pleurisy[merriam-webster.com]
Chest Pain
  • Symptoms might include: Chest pain Fever When to see a doctor Seek emergency care for persistent chest pain, which may indicate a recurring heart attack or other disorder.[drugs.com]
  • The disease consists of a persistent low-grade fever , chest pain (usually pleuritic in nature), pericarditis (usually evidenced by a pericardial friction rub ), and/or a pericardial effusion .[en.wikipedia.org]
Pericardial Friction Rub
  • Physical examination revealed jugular venous distention and pulsus paradoxus but no pericardial friction rub. Cine magnetic resonance imaging showed massive pericardial effusion (arrows) and a swinging motion of the heart ( video clip ).[nejm.org]
  • The disease consists of a persistent low-grade fever , chest pain (usually pleuritic in nature), pericarditis (usually evidenced by a pericardial friction rub ), and/or a pericardial effusion .[en.wikipedia.org]
  • Examination revealed signs of a pericardial friction rub and bilateral pleural effusions but no evidence of cardiac tamponade.[mja.com.au]
Heart Disease
  • diseases I24.0 Acute coronary thrombosis not resulting in myocardial infarction I24.1 Dressler's syndrome I24.8 Other forms of acute ischemic heart disease I24.9 Acute ischemic heart disease, unspecified I25 Chronic ischemic heart disease I25.1 Atherosclerotic[icd10data.com]
  • Code Classification Diseases of the circulatory system (I00–I99) Ischemic heart diseases (I20-I25) Other acute ischemic heart diseases (I24) Information for Medical Professionals Diagnostic Related Groups The diagnosis code I24.1 is grouped in the following[icdlist.com]
  • Other NSAIDs though once used to treat Dressler syndrome, are less advocated and should be avoided in patients with ischemic heart disease.[en.wikipedia.org]
  • NSAIDs other than aspirin are not actively advocated and better avoided in patients with ischemic heart disease. Indomethacin, in particular, is known to inhibit new collagen deposition thus impairing the healing of the infarcted region.[xpertdox.com]
Tachycardia
  • Dressler beat - presence of Dressler beats strongly supporting the diagnosis of ventricular tachycardia by interruption of it. Dressler syndrome - Synonym(s): pericarditis[medical-dictionary.thefreedictionary.com]
  • […] cases of pericarditis described following pericardiotomy [ 8 ], chest trauma [ 9 ], myopericarditis [ 10 ], pacemaker implantation [ 11 , 12 ], percutaneous puncture of the left ventricle [ 13 ], radiofrequency ablation of idiopathic left-ventricular tachycardia[em-consulte.com]
  • Search dictionary help Dressler beat medical dictionary Fusion beat interrupting a ventricular tachycardia and producing a normally narrow QRS complex as a result of the fusion of two impulses , one impulse from the ventricular tachycardia and the other[mondofacto.com]
  • tachycardia (VT), and ventricular fibrillation (VF).[msdmanuals.com]
  • Example 2 Acute Pericarditis: Sinus tachycardia Widespread concave STE and PR depression (I, II, III, aVF, V4-6). Reciprocal ST depression and PR elevation in V1 and aVR.[lifeinthefastlane.com]
Retrosternal Chest Pain
  • chest pain, joint pain and decreased oxygen saturation can also be seen in some cases. [1] One problem with this definition is that it is so non specific.[en.wikipedia.org]
  • chest pain, often radiating to the neck, shoulders, or back.[clevelandclinicmeded.com]

Workup

Work up approach considrations in dressler syndrome includes initial baseline laboratory investigations, cardiac imaging, and pericardiocentesis.

Complete blood count reveals leukocytosis with left shift. However, blood cultures are typically negative to rule out a bacterial cause of acute pericarditis. Blood cultures are, therefore, very necessary as part of the initial laboratory studies. Serology reveals a high titer of antimyocardial antibodies. Typically, erythrocyte sedimentation rate (ESR) and C-reactive protein level are evelated. Cardiac enzyme levels are not necessary in the diagnosis of dressler syndrome as results remain unchanged as in patients without dressler syndrome who have had pericardial injury or myocardial infarction. As part of baseline investigations, pericardial fluid should be sent for microscopic analysis, biochemistry, and cultures.

Cardiac imaging includes electrocardiography (ECG), chest radiography, echocardiography, and cardiac magnetic imaging resonance (MRI) which are all indicated in dressler syndrome. However, echocardiography is the diagnostic modality of choice in dressler syndrome.

Chest radiographs typically show effacement of the costophrenic angles from pleural effusion, and an enlarged cardiac silhouette due to pericardial effusion

Findings on the ECG include T-wave inversion, low QRS amplitude, and ST segment elevation. A low QRS amplitude is most commonly seen if the pericardial effusion is massive. 

The echocardiography is more sensitive than chest radiography [12]. Echocardiography helps exclude other differentials such as congestive heart failure with the characteristic finding of fluid collection posterior to the left ventricle during systole. Cardiac MRI is indicated to clearly reveal pericardial fluid collection which has not been clearly delineated with echocardiography.

Pericardiocentesis is both a diagnostic and therapeutic procedure. Pericardial inflammation causes effusion and collection of fluid in the pericardial potential space, overtime, the fluid accumulated makes the pericardium massively enlarged compressing the heart, thereby restricting outflow and cardiac output. This is called cardiac tamponade and it requires urgent management. Echocardiography-guided pericardiocentesis is the recommended initial management method for significant pericardial effusion and cardiac tamponade. The drainage is usually done over 24-48 hours.

Pericardial Effusion
  • ECG may show ST elevation in most leads without reciprocal ST depression, typical of pericardial effusion. Echocardiography shows pericardial effusion.[patient.info]
  • The disease consists of a persistent low-grade fever , chest pain (usually pleuritic in nature), pericarditis (usually evidenced by a pericardial friction rub ), and/or a pericardial effusion .[en.wikipedia.org]
  • The pericardial effusion cleared with short-term therapy with corticosteroids and the prolonged use of indomethacin.[unboundmedicine.com]
  • The symptoms mainly consist of fever, pleuritic pain , pericarditis and pericardial effusion .[xpertdox.com]
ST Elevation
  • At presentation, an electrocardiogram demonstrated 1–2 mm ST elevation in leads V1–V6, I and aVL ( Box 1 ).[mja.com.au]
  • The ECG showed anterolateral ST elevation and because of this and ongoing pain, she was thrombolysed with retaplase despite the late presentation.[jcmr-online.biomedcentral.com]
Pleural Effusion
  • […] silhouette enlargement from pericardial effusion and mild to moderate-sized left (usually) pleural effusion Pleural effusion may be bilateral Pleural effusions (83%) Parenchymal opacities (74%) Enlarged cardiac silhouette from pericardial effusion (49%[learningradiology.com]
  • A small pleural effusion (black arrow) is also visible.[mja.com.au]
  • Dressler's Syndrome:pericarditis after heart attack or open-heart surgery that is often recurrent and is typically accompanied by chest pain, fever, pericardial and pleural effusions, pleurist, lung infiltrates, and joint pain.[echopedia.org]
  •  Symptoms appear 2-3 weeks following infarct/surgery–sometimes years  Chest pain (91%), fever, pericardial and pleural effusion  Also rales, SOB and leukocytosis  Pleural tap: bloody exudate[learningradiology.com]
Pleural Rub
  • Sometimes pleural rubs can also be auscultated when the pleura are involved. This can be distinguished from pericardial rubs by asking the patient to halt respirations.[clinicaladvisor.com]

Treatment

Initial evaluation and treatment of dresser syndrome in a hemodynamically stable patient is usually on an outpatient basis. Initial care is largely conservative with nonsteroidal anti-inflammatory drugs prescribed for up to 6 weeks, doses of which are tapered as the collected fluid reduces. Corticosteroids are indicated if treatment with NSAIDs fail to resolve the inflammatory process. Certain reports have revealed successful treatment of recurrent cases of dressler syndrome with a single high dose of intravenous immunoglobulin in a patient and a weekly administration of low dose methotrexate in another patient [13].

More severe cases, especially involving cardiac tamponade are managed as emergencies in an inpatient setting. Cardiac tamponade is treated with urgent pericardiocentesis, after which patients may be continued on outpatient care, if they show satisfactory improvement.

Surgery is indicated in cases of relapse or persistence of symptoms despite medical treatment. Surgical procedures indicated in these cases include open thoracotomy or video-assisted thoracoscopy and percutaneous gallon pericardiotomy [14]. These procedures basically serve the same purpose: creation of a pericardial window through which pericardial fluid drains. However, percutaneous balloon pericardiotomy is less invasive and involves flouroscopic-guided balloon catheterization [15]. In this procedure, the pericardial fluid is shunted through a surgical defect in the diaphragm into the abdominal cavity.

Prognosis

Generally, the prognosis of dressler syndrome is benign, with the outcome largely determined by the severity of the underlying cardiac disease. Most cases of dressler syndrome resolve within a few weeks, however, in a few cases, the symptoms may persist for a number of months. Relapses occur in up to 15% of patients [9]. Most relapses occur within 6 months of the inciting surgery or injury.

Complications of dressler syndrome include cardiac tamponade, constrictive pericarditis, hypoxaemia, and occlusion of a coronary bypass graft. Constrictive pericarditis is however, neither exclusively nor frequently caused by dressler syndrome.

Cardiac tamponade is the restriction of ventricular filling and outflow sequel to massive effusion and thickening of the pericardium. Cardiac tamponade, being a life-threatening condition, requires urgent pericardiocentesis. Cardiac tamponade occurs in about 1% of cases of dressler syndrome. In addition, occlusion of a coronary bypass graft is a rare complication of dressler syndrome.

Etiology

Dressler syndrome has an unknown etiology, however autoimmunity has been associated with its pathogenesis [5]. This is suggested by serologic findings of antimyocardial antibodies. However, the presence of these antibodies are yet to be linked to either the cause or the result of this syndrome. Reports of pericardial surgeries showed that a high titer of the anti myocardial antibodies was associated with the development of dressler syndrome.

Epidemiology

Dressler syndrome was first described by Dressler in 1956 in which he noted that the syndrome had an incidence rate of 3-4% of all cases of acute myocardial infarction [6]. However, the incidence rate is now much reduced because of better treatment methods for acute myocardial infarction. Dressler syndrome is rarely seen in children under 2 years.

Sex distribution
Age distribution

Pathophysiology

The etiology and pathogenesis of dressler syndrome is not clearly understood, however, studies show that it most likely has an autoimmune basis [7]. Other hypotheses include viral infections and localized inflammatory processes. In over 60% of cases, viruses including cytomegalovirus, coxackie B and adenovirus, have been shown to be present in patients with this syndrome, thus suggesting that the syndrome may be an antibody response to a viral infection. Nonetheless, a study showed no presence of viruses in patients with the syndrome postpericardiotomy [8]. Dressler syndrome is most commonly associated with intramural myocardial infarction.

Prevention

The incidence of Dressler's syndrome is much reduced by use of NSAIDs post-pericardial or cardiac surgery. However, prophylactic steroid use prior to cardiac surgery doesn't prevent this syndrome [16].

Summary

Dressler syndrome is an inflammatory reaction involving the pericardium, often occurring secondary to pericardial surgeries, injuries, and myocardial infarction, hence, Dressler syndrome is also referred to as post-myocardial infarction syndrome and postpericardiotomy syndrome [1]. Other common triggers of dressler syndrome include heart puncture, blunt trauma, pacemaker implantation, and coronary stenting [2].

The syndrome presents as an acute pericarditis with low grade fever, pleuritic chest pain, pericardial friction rubs and pericardial effusion which could progress into cardiac tamponade, a life-threatening condition [3] [4]. In a few recurrent cases of dressler syndrome, cardiac tamponade may also recur. Dressler syndrome, in few cases, may recur years after the inciting surgery and initial treatment.

Diagnosis of dressler syndrome is largely clinical, with characteristic findings on physical examination including pericardial friction rub, and a history of myocardial infarction, cardiac surgeries or injuries. Although, dressler syndrome is somewhat similar to peri-infarction pericarditis which follows a myocardial infarction, dressler syndrome often presents several weeks to months after an infarction as opposed to the early onset of peri-infarction pericarditis.

Common surgical procedures associated with the development of dressler syndrome include surgical corrections of atrial septal defects, ventricular septal defects and fallot's tetralogy, and cardiac transplantation.

The pathophysiology of dressler syndrome is not clearly understood, however, it is theorized to be a result of an autoimmune process, as evidenced by the presence of antimyocardial antibodies, and its sensitivity to anti-inflammatory drugs.

Clinical evaluation is always supported by laboratory investigation to confirm a diagnosis of dressler syndrome. Cardiac imaging provides characteristic features for the diagnosis and could be employed therapeutically to treat this syndrome. Treatment involves drainage of the peicardial fluid and administration of anti-inflammatory drugs. Cardiac tamponade is, however, treated as an emergency with an urgent drainage of the collected pericardial fluid.

Patient Information

Dressler syndrome is an inflammatory condition of the covering of the heart, the pericardium, after a heart attack, or after an injury or surgical procedure involving the heart or the pericardium. It is a condition characterised by chest pain, and fever. This pericardium is made up of two layers.

Causes

Doctors are not so clear about how the disease results, although they have postulated a theory, based on findings in a lot of cases, that the disease may result from the body's antibodies attacking the heart and pericardium. The antibodies were originally meant to repair the damaged heart tissue, but end up damaging it by causing excessive inflammation.

Symptoms

Dressler syndrome typically presents with pain in the middle of the chest which gets worse with lying flat and is  relieved by leaning forward. The pain is usually described as an intermittent squeezing, burning sensation as opposed to a heart attack in which the pain is continuous. Another common symptom of this disease is a mild fever.

Prognosis

The inflammation of the pericarditis leads to release of fluids from the blood vessels around the pericardium. This fluid collects gradually, and if the condition is untreated, may collect till it becomes massive compressing the heart and restricting the heart's ability to pump out blood. This phenomenon is called cardiac tamponade and is a medical emergency.

Diagnosis

Doctors can make a diagnosis of dressler syndrome from the history and examination findings. A history of the typical chest pain and fever which occur after heart surgery or a heart attack suggests dressler syndrome. Your doctor would listen for a typical sound called pericardial rub, on placing the stethoscope on your chest. This sound is due to the irritation of the two layers of the pericardium when you breathe.

To confirm this diagnosis, however, your doctor may require radiological films including Chest X-ray, CT scan, echocardiography, and magnetic resonance imaging (MRI) of the heart. An electrocardiogram (ECG) may also be necessary. The echocardiograph is a technique which uses very high frequency sound waves to create an image of the heart to reveal the characteristic fluid collection in the pericardium and exclude other diseases which could cause similar symptoms. The ECG uses electrical wires plugged to the chest to check for the changes in the electrical activity of the heart.

Blood tests would also be ordered to reveal features characteristic of this condition.

Treatment

Treatment of this condition basically includes administration of over-the-counter pain medications such as advil and aspirin. Steroids are powerful immune suppressants which also serve to reduce the inflammation and pain in this condition. Doctors use steroids in testing dressler syndrome when over-the-counter pain medications do not resolve the symptoms.

The complications of this condition would also be treated. Cardiac tamponade is treated with urgent drainage of the fluid using a catheter. In severe and recurrent cases, surgery may be necessary to drain the fluid from the pericardium. Such surgical procedures create a hole in the pericardium through which the fluid drain to another safe site, usually in the abdomen.

References

Article

  1. Hutchcroft BJ. Dressler's syndrome. Br Med J. 1972 Jul 1; 3(5817):49.
  2. Tabatznik B, Isaacs JP. Postpericardiotomy syndrome following traumatic hemopericardium. Am J Cardiol. 1961 Jan; 7:83-96.
  3. Herrera-Franco R, Narvaez-Rivera JL, Benitez-Perez C, et al. Recurrent cardiac tamponade secondary to postpericardiotomy syndrome. Gac Med Mex. 1999 Nov-Dec; 135(6):593-7.
  4. Cabalka AK, Rosenblatt HM, Towbin JA, et al. Postpericardiotomy syndrome in pediatric heart transplant recipients. Immunologic characteristics. Tex Heart Inst J. 1995; 22(2):170-6.
  5. Braunwald E, Zipes DP, Libby P, editors. Heart disease: a textbook of cardiovascular medicine. 6th ed. Philadelphia: WB Saunders; 2001.
  6. 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.
  7. Wessman DE, Stafford CM. The postcardiac injury syndrome: case report and review of the literature. South Med J. 2006 Mar; 99(3):309-14.
  8. Webber SA, Wilson NJ, Junker AK, et al. Postpericardiotomy syndrome: no evidence for a viral etiology. Cardiol Young. 2001 Jan; 11(1):67-74.
  9. Prince SE, Cunha BA. Postpericardiotomy syndrome. Heart Lung 1997; 26:165–8.
  10. Hendry C, Liew C, Chauhan A, et al. A life-saving case of Dressler's syndrome Eur Heart J Acute Cardiovasc Care. 2012 Sep; 1(3):232-235.
  11. Steadman C, Khoo J, Kovac J, et al. Dressler's syndrome demonstrated by late gadolinium enhancement cardiovascular magnetic resonance J Cardiovasc Magn Reson. 2009; 11(1):23.
  12. Tingle L, Molina D, Calvert C. Acute pericarditis. Am Fam Physician. 2007 Nov 15; 76(10):1509-14.
  13. Zucker N, Levitas A, Zalzstein E. Methotrexate in recurrent postpericardiotomy syndrome. Cardiol Young. 2003 Apr; 13(2):206-8.
  14. Hazelrigg SR, Mack MJ, Landreneau RJ, Acuff TE, Seifert PE, Auer JE. Thoracoscopic pericardiectomy for effusive pericardial disease. Ann Thorac Surg. 1993 Sep; 56(3):792-5.
  15. Forbes TJ, Horenstein MS, Vincent JA. Balloon pericardiotomy for recurrent pericardial effusions following fontan revision. Pediatr Cardiol. 2001 Nov-Dec; 22(6):527-9.
  16. Wessman DE, Stafford CM. The postcardiac injury syndrome: case report and review of the literature. South Med J. 2006 Mar; 99(3):309-14.

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Last updated: 2018-06-22 07:30