Post cardiac injury syndrome

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Ibtisam Ashraf, M.B.B.S.[2]

Synonyms and keywords: PCIS

Overview

Post cardiac injury syndrome (PCIS) encompasses three causes of pericarditis: Post myocardial infarction syndrome (PMIS) or Dressler's syndrome, Postpericardiotomy syndrome (PCS) and Posttraumatic pericarditis.

Historical Perspective

• Dressler's syndrome was first discovered by William Dressler, a Jewish-American Cardiologist at Maimonides Medical Centre, in 1956.
• Postcommissurotomy syndrome, initially described in 1952 in patients undergoing mitral valve surgery. It was later renamed to Postpericardiotomy syndrome in 1958.

Classification

Post cardiac injury syndrome(PCIS)

Post-myocardial infarction pericarditis

Post-pericardiotomy syndrome (PPS)

Post-traumatic pericarditis

Early infarct-associated pericarditis

Late post-myocardial infarction pericarditis (Dressler's Syndrome)

Thoracic trauma

Iatrogenic trauma

Pathophysiology

Both syndromes represent the delayed occurrence of pericarditis. Post-myocardial infarction syndrome is obviously due to myocardial infarction and postpericardiotomy syndrome is due to the myocardial injury that occurs during cardiac surgery. The initial trigger seems to be the combination of damage occurring to the pericardial or pleural mesothelial cells and blood entering the pericardial space which causes the release of cardiac antigens into the circulation. It leads to the formation of immune complexes which get deposited into the pericardium, pleura, lungs, joints etc eliciting an inflammatory response.

Clinical Features

Specific symptoms of post-cardiac injury syndrome include:

• Pleuritic chest pain
• Fever
• Elevated markers of inflammation
• Pericardial effusion
• Pleural effusion
• Pulmonary infiltrates

Differentiating Post cardiac injury syndrome from other Diseases

• PCIS must be differentiated from other diseases that cause fever, chest pain and pleuropericardial effusion, such as:

• Pleuritis or Pleuropericarditis
• Pulmonary embolism
• Boerhaave Syndrome
• Blunt chest wall trauma
• Pneumothorax
• Connective tissue disorders (e.g SLE)

Epidemiology and Demographics

• Incidence: Dressler's syndrome was reported to occur in about 3 to 4% of MI cases. Now it has been markedly decreased due to improvements in the management of Myocardial infarction which result in the small infarct size whereas postpericardiotomy syndrome has been reported in 10 to 40% of patients after cardiac surgery.

Age

• Dressler's syndrome occurs more often in younger age groups.
• The risk of postpericardiotomy syndrome (PPS) increases with age.

Gender

• Female gender is an independent risk factor for postpericardiotomy syndrome.

Race

• There is no racial predilection for post cardiac injury syndrome.

Risk Factors

These are the factors which increase the risk of post cardiac injury syndrome:

• Cardiac Surgery (including AVR, MVR and aortic surgery)
• Young age
• Previous pericarditis
• Viral Infection
• Prior treatment with prednisone
• Blood type B negative
• Halothane anesthesia

Natural History, Complications and Prognosis

Natural History

• Post cardiac injury syndrome usually occurs in 1 to 6 weeks after initial pericardial injury.
• Most patients presents with fever which subsides within 2-3 weeks.

Complications

Rare complications include the development of:

• Cardiac tamponade
• Pericardial constriction
• Saphenous vein graft occlusion

Prognosis

• Post cardiac injury syndrome has relatively a good prognosis.
• The recurrence rate is reported to be 10-15% but has a small risk of developing constrictive pericarditis which requires a long term follow-up.

Diagnosis

Diagnostic Criteria

• Dressler syndrome typically occurs 1–2 weeks after STEMI. Its diagnostic criteria do not differ from those for acute pericarditis including two of the following criteria: (i) Pleuritic chest pain; (ii) Pericardial friction rub; (iii) ECG changes (new widespread ST-segment elevation and PR depressions in multiple leads (except for aVR and V1); and (iv) Pericardial effusion.
• Diagnostic criteria for Postpericardiotomy Syndrome include the presence of at least two of the following five symptoms: (i) new or worsening pleural effusion, (ii) new or worsening pericardial effusion, (iii) fever without alternative causes, (iv) pleuritic chest pain, and (v) pleural or pericardial rubbing

Symptoms

Both syndromes share common symptoms which include fever and pleuritic pain.

Physical Examination

The following findings may be present:

Cardiovascular

A pericardial friction rub

Lungs

A pleural effusion

Laboratory Studies

The following lab abnormalities may be present:

• An elevated erythrocyte sedimentation rate.
• A leukocytosis.

Chest x-ray

A pleural effusion with or without pulmonary infiltrates may be present.

Electrocardiogram

The change of ECG from the baseline and showing the following findings can be suggestive of pericarditis:

• Diffuse ST-segment elevation with PR depression

Echocardiography

It can be used to

• Determine the presence or absence of pericardial effusion and
• Rule out the possibility of cardiac tamponade.

Cardiac MRI

To assess the posterior pericardium, which is difficult to visualize with the echocardiogram.

Treatment

Dressler's syndrome is typically treated with high dose (up to 650 mg PO q 4 to 6 hours) enteric-coated aspirin. Acetominophen 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.

NSAIDs such as ibuprofen should be avoided in the peri-infarct period as they:

1. Increase the risk of reinfarction
2. Adversely impact left ventricular remodeling.
3. Block the effectiveness of aspirin

Treatment

Medical Therapy

• The mainstay of therapy for postcardiac injury syndrome is Anti-inflammatory NSAIDs in combination with colchicine.
• Aspirin is preferred in postmyocardial infarction pericarditis.
• Recurrent cases can be treated with glucocorticoids in combination with aspirin and colchicine.

Surgery

• Surgical intervention is not recommended for the treatment of post cardiac injury syndrome.
• Pericardiocentesis with catheter drainage is considered the standard of care for patients with a significant pericardial effusion due to complications of PCIS (i.e cardiac tamponade or constrictive pericarditis).

Prevention

• Colchicine significantly reduces the incidence of post cardiac injury syndrome.

ACC/AHA Treatment Guidelines (DO NOT EDIT)

“

Class I 1. Aspirin is recommended for treatment of pericarditis after STEMI. Doses as high as 650 mg orally (entericcoated) every 4 to 6 hours may be needed. (Level of Evidence: B) 2. Anticoagulation should be immediately discontinued if pericardial effusion develops or increases. (Level of Evidence: C) Class IIa 1. For episodes of pericarditis after STEMI that are not adequately controlled with aspirin, it is reasonable to administer 1 or more of the following: a. Colchicine 0.6 mg orally every 12 hours (Level of Evidence: B) b. Acetaminophen 500 mg orally every 6 hours. (Level of Evidence: C) Class IIb 1. Corticosteroids might be considered only as a last resort in patients with pericarditis refractory to aspirin or NSAIDs. Although corticosteroids are effective for pain relief, their use is associated with an increased risk of scar thinning and myocardial rupture. (Level of Evidence: C) 2. Nonsteroidal anti-inflammatory drugs may be considered for pain relief; however, they should not be used for extended periods because of their effect on platelet function, an increased risk of myocardial scar thinning, and infarct expansion. (Level of Evidence: B) Class III 1. Ibuprofen should not be used for pain relief because it blocks the antiplatelet effect of aspirin and it can cause myocardial scar thinning and infarct expansion. (Level of Evidence: B)

”

Sources

• The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction

• The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction