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This is classically a post-myocardial infarction syndrome, usually occurring two to five weeks after the initial event but it can be delayed for as long as three months. See also the separate article on Complications of Acute Myocardial Infarction.
Dressler’s syndrome was first described in 1956. 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. It is thought to be immune-mediated (antiheart antibodies may be present). The reported incidence has been declining in recent years.
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. Post-pericardiotomy syndrome has been observed after cardiac surgery, percutaneous intervention, pacemaker implantation, radiofrequency ablation and pulmonary vein isolation.[2, 3, 4]
The original paper by Dressler in 1956 suggested an incidence of 3-4% of all cases of acute myocardial infarction.It is now much rarer, probably due to modern methods of management of an acute myocardial infarction.
One reason may be that active intervention reduces the size of the infarct. Some have argued that the syndrome has not vanished but rather never really existed as a separate entity.
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 two to five weeks 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.
- FBC will show leukocytosis, 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.
- CXR shows pleural effusions in 83%, parenchymal opacities in 74%, and an enlarged cardiac silhouette in 49%.
- Aspirin may be given in large doses.
- Other non-steroidal anti-inflammatory drugs (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, depending on the nature and severity of co-existing heart disease.
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. Prophylactic use of steroids before cardiac surgery offers no benefit.
Further reading and references
Guidelines on the diagnosis and management of pericardial diseases; European Society of Cardiology (2004)
Hendry C, Liew CK, Chauhan A, et al; A life-saving case of Dressler's syndrome. Eur Heart J Acute Cardiovasc Care. 2012 Sep1(3):232-5. doi: 10.1177/2048872612452319.
Bucekova E, Simkova I, Hulman M; Postpericardiotomy syndrome - post-cardiac injury syndrome. Bratisl Lek Listy. 2012113(8):481-5.
Wessman DE, Stafford CM; The postcardiac injury syndrome: case report and review of the literature. South Med J. 2006 Mar
Luckie M, Jenkins NP, Davidson NC, et al; Dressler's syndrome following pulmonary vein isolation for atrial fibrillation. Acute Card Care. 200810(4):234-5.
Dressler W; A post-myocardial infarction syndrome preliminary report of a complication resembling idiopathic, recurrent, benign pericarditis.
Pasotti M, Prati F, Arbustini E; The pathology of myocardial infarction in the pre and post interventional era. Heart. 2006 Apr 18
Bendjelid K, Pugin J; Is Dressler syndrome dead? Chest. 2004 Nov
Steadman CD, Khoo J, Kovac J, et al; Dressler's syndrome demonstrated by late gadolinium enhancement cardiovascular J Cardiovasc Magn Reson. 2009 Jul 2311(1):23.
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