Dressler's syndrome

WikiDoc Resources for Dressler's syndrome
Articles
Most recent articles on Dressler's syndrome Most cited articles on Dressler's syndrome Review articles on Dressler's syndrome Articles on Dressler's syndrome in N Eng J Med, Lancet, BMJ
Media
Powerpoint slides on Dressler's syndrome Images of Dressler's syndrome Photos of Dressler's syndrome Podcasts & MP3s on Dressler's syndrome Videos on Dressler's syndrome
Evidence Based Medicine
Cochrane Collaboration on Dressler's syndrome Bandolier on Dressler's syndrome TRIP on Dressler's syndrome
Clinical Trials
Ongoing Trials on Dressler's syndrome at Clinical Trials.gov Trial results on Dressler's syndrome Clinical Trials on Dressler's syndrome at Google
Guidelines / Policies / Govt
US National Guidelines Clearinghouse on Dressler's syndrome NICE Guidance on Dressler's syndrome NHS PRODIGY Guidance FDA on Dressler's syndrome CDC on Dressler's syndrome
Books
Books on Dressler's syndrome
News
Dressler's syndrome in the news Be alerted to news on Dressler's syndrome News trends on Dressler's syndrome
Commentary
Blogs on Dressler's syndrome
Definitions
Definitions of Dressler's syndrome
Patient Resources / Community
Patient resources on Dressler's syndrome Discussion groups on Dressler's syndrome Patient Handouts on Dressler's syndrome Directions to Hospitals Treating Dressler's syndrome Risk calculators and risk factors for Dressler's syndrome
Healthcare Provider Resources
Symptoms of Dressler's syndrome Causes & Risk Factors for Dressler's syndrome Diagnostic studies for Dressler's syndrome Treatment of Dressler's syndrome
Continuing Medical Education (CME)
CME Programs on Dressler's syndrome
International
Dressler's syndrome en Espanol Dressler's syndrome en Francais
Business
Dressler's syndrome in the Marketplace Patents on Dressler's syndrome
Experimental / Informatics
List of terms related to Dressler's syndrome

For patient information click here

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

WikiDoc Resources for Dressler's syndrome
Articles
Most recent articles on Dressler's syndrome Most cited articles on Dressler's syndrome Review articles on Dressler's syndrome Articles on Dressler's syndrome in N Eng J Med, Lancet, BMJ
Media
Powerpoint slides on Dressler's syndrome Images of Dressler's syndrome Photos of Dressler's syndrome Podcasts & MP3s on Dressler's syndrome Videos on Dressler's syndrome
Evidence Based Medicine
Cochrane Collaboration on Dressler's syndrome Bandolier on Dressler's syndrome TRIP on Dressler's syndrome
Clinical Trials
Ongoing Trials on Dressler's syndrome at Clinical Trials.gov Trial results on Dressler's syndrome Clinical Trials on Dressler's syndrome at Google
Guidelines / Policies / Govt
US National Guidelines Clearinghouse on Dressler's syndrome NICE Guidance on Dressler's syndrome NHS PRODIGY Guidance FDA on Dressler's syndrome CDC on Dressler's syndrome
Books
Books on Dressler's syndrome
News
Dressler's syndrome in the news Be alerted to news on Dressler's syndrome News trends on Dressler's syndrome
Commentary
Blogs on Dressler's syndrome
Definitions
Definitions of Dressler's syndrome
Patient Resources / Community
Patient resources on Dressler's syndrome Discussion groups on Dressler's syndrome Patient Handouts on Dressler's syndrome Directions to Hospitals Treating Dressler's syndrome Risk calculators and risk factors for Dressler's syndrome
Healthcare Provider Resources
Symptoms of Dressler's syndrome Causes & Risk Factors for Dressler's syndrome Diagnostic studies for Dressler's syndrome Treatment of Dressler's syndrome
Continuing Medical Education (CME)
CME Programs on Dressler's syndrome
International
Dressler's syndrome en Espanol Dressler's syndrome en Francais
Business
Dressler's syndrome in the Marketplace Patents on Dressler's syndrome
Experimental / Informatics
List of terms related to Dressler's syndrome

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.

Classification

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

Pathophysiology

• Although the exact cause remains unknown, Dressler's syndrome is believed to result from an autoimmune inflammatory reaction to myocardial neo-antigens, as well as injury to the mesothelial pericardial cells.
• It usually occurs within weeks or months of the infarction due to antimyocardial antibodies; this begins with myocardial injury that releases cardiac antigens and stimulates antibody formation.
• The immune complexes that are generated as anti-actin and actomyosin antibodies deposit onto the pericardium and causes inflammation.
• The autoimmune response and syndrome may also develop secondary to pulmonary embolism.

Gross Pathology

Gross pathological examination may show the following findings:

• Fine granular layer on the epicardial surface with a “bread and butter” appearance.
• Because Dressler's syndrome is more common with transmural infarctions, the causing infarction is likely to be seen.

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.

Microscopic Pathology

Microscopic examination of the myocardial tissue sections may show:

• Plurifocal signs of myocardial sclerosis may be detected.
• Lymphocytic perimyofibrillar microinfiltrations may be seen.
• Localized lipofuscin pigment deposits in the myocytes.

Causes

The common causes of Dressler's syndrome include:

• Surgeries associated with myocardial damage
  • Coronary artery bypass grafting and
  • Aortic valve replacement.
• Myocardial infarction
• Pulmonary embolism

Differentiating Dressler's Syndrome from other Diseases

• Dressler's syndrome typically occurs 2 to 10 weeks after a myocardial infarction has occurred.
• This differentiates Dressler's syndrome from:

• • Post myocardial infarction pericarditis that occurs in 17,000 to 25,000 in every 100,000 cases of acute myocardial infarction between days 2 and 4 after the myocardial infarction.

• • Pulmonary embolism, another identifiable cause of pleuritic (and non-pleuritic) chest pain in people who have been hospitalized and/or undergone surgical procedures within the preceding weeks.

• Dressler's syndrome should be differentiated from:

• • Congestive Heart Failure: Another complication of MI that may occur in a more acute setting.
  • Acute anemia (e.g., hemorrhage): shares the same symptoms as malaise, dyspnea, and palpitations.
  • Uremia: may lead to pericarditis that must be differentiated from Dressler's syndrome.

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.
• However, the incidence has markedly decreased in the reperfusion era (between 0.5 to 2%), presumably because of smaller infarct sizes.
• 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:

• • Cardiac surgeries associated with greater myocardial damage as aortic valve replacement
  • Younger age
  • Prior treatment with prednisone
  • B-negative blood type
  • Halothane anesthesia
  • Viral infections that have been associated with Dressler's syndrome (based on the seasonal variations in incidence and elevated blood levels of viral components in Dressler's Syndrome patients), including:
    • Coxsackie B virus
    • Adenovirus
    • Cytomegalovirus

Screening

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

Natural History, Complications, and Prognosis

Natural History

• Dressler's syndrome typically occurs 2 to 10 weeks after a myocardial infarction has occurred.
• The symptoms for Dressler's syndrome starts mild and then progress to reach the full clinical profile.
• The condition is usually acute; however, some patients may develop chronic pericardial inflammation.
• The prognosis is usually favorable with early treatment.
• Untreated or poorly treated patients may develop cardiac tamponade (acute) or constrictive pericarditis (chronic).

Complications

The complications of Dressler's syndrome may include:

• Pericardial effusion may result from the accumulation of fluids as a result of inflammation in the pericardial sac.
• Cardiac tamponade can occur if the accumulation of fluids in the pericardium is large enough and rapid enough.
• Constrictive pericarditis can occur if there is a chronic inflammatory response.

Prognosis

• The prognosis for patients with Dressler's syndrome is usually favorable, even those requiring pericardial drainage.
• However, the latter patients have a higher risk for fluid reaccumulation and repeat pericardiocentesis.  
• Otherwise, constrictive pericarditis would occur leading to the need for pericardial stripping.

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)".

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:

• Malaise
• Irritability
• Lack of appetite
• Difficulty breathing (with or without hypoxia)
• Palpitations
• Pain in the joints

Physical Examination

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

• Pericardial friction rub: This characteristic sign may disappear secondary to either improvement in or worsening of accumulation of pericardial fluid
• Tachycardia
• Pulsus paradoxus (>10 mmHg decrease in blood pressure with inspiration and decreased pulse amplitude on the radial artery).
• Signs of pneumonitis (e.g., a cough, decreased oxygen saturation, and fever).
• Minimal respiratory symptoms to significant respiratory distress with large pleural effusions.

Laboratory Findings

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

• Blood culture: can differentiate between inflammatory and infectious pericarditis (should be negative in Dressler's syndrome)

• Leucocytosis (with a leftward shift)
• Elevated acute phase reactants (e.g., ESR and CRP)
• High serum titers of anti-cardiac antibodies
• The pericardial fluid may be examined for cell count, culture, total proteins, and triglyceride levels

Electrocardiogram

An ECG may demonstrate:

• ST segment elevation
• T-wave inversion (as with pericarditis).
• PR depression
• Variations in the amplitude or directionality of QRS from beat to beat and/or a low voltage QRS

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

X-ray

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

• Flattening of the costophrenic angles

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

Echocardiography or Ultrasound

• Echocardiography is used to:
  • Confirm the presence of pericardial fluid and evaluate the potential risk of cardiac tamponade.
  • Evaluate ventricular contractility and the potential risk of congestive heart failure.

CT scan

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

• Pericardial effusion of varying size, which may be simple (serous) or more often complex (hemopericardium)
• Myocardial thinning of the infarcted region
• Stents in the coronary arteries (e.g., post PCI) may be present

MRI

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

• Fluid collections in the pericardium (may become loculated).

• Intense late post-gadolinium enhancement of entire pericardium.
• Regional thinning and akinesis of the infarcted myocardium.

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.

"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".

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.

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.
  

See also

• Pericarditis
• Postpericardiotomy syndrome
• Myocardial infarction
• Coronary artery bypass graft

de:Dressler-Syndrom

Template:WikiDoc Sources