Dressler Syndrome


Article Author:
Ari Leib
Lisa Foris
Tran Nguyen


Article Editor:
Karam Khaddour


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
7/4/2019 9:02:04 AM

Introduction

Dressler syndrome (DS), also known as postmyocardial infarction syndrome, is a form of secondary pericarditis with or without a pericardial effusion, that occurs as a result of injury to the heart or pericardium [1]. Though not a common condition, DS should be considered in all patients presenting with persistent malaise or fatigue, following a myocardial infarction (MI) or cardiac surgery, especially if symptoms present greater than two weeks following the event [2]

Etiology

Pericarditis is a condition in which the pericardium (a fibroelastic sac surrounding the heart and comprised of a parietal and visceral layer which is separated by a potential space) becomes inflamed. Under normal circumstances, the pericardial cavity holds 15 to 50mL of pericardial fluid (an ultrafiltrate of plasma).

DS is part of a group of post-cardiac injury syndromes, which include:

  1. postpericardiotomy syndrome
  2. post-traumatic pericarditis from blunt or penetrating trauma
  3. iatrogenic causes including
    1. percutaneous coronary or intracardiac interventions 
    2. pacemaker lead insertion,
    3. radiofrequency ablation [3] [4] [5]

Each represents a different clinical condition characterized by an initial cardiac injury involving the pericardium/myocardium and/or pleura and the subsequent inflammatory syndrome ranging from simple, uncomplicated pericarditis to more complicated cases with pleuropericarditis, cardiac tamponade, or massive pleural effusion [6].

The exact cause of DS is not known, though it is presumed that an initial injury to mesothelial pericardial cells combined with blood in the pericardial space triggers an immune response and results in immune complex deposition in the pericardium, pleura, and lungs which cause an inflammatory response [7].

This theory is supported by a number of observations regarding post-cardiac injury syndromes. There is often a distinct latency period observed at the time of cardiac injury and the development of a post-cardiac injury syndromes, with symptoms typically starting anywhere from 3-4 days to 2-6 weeks post injury(with occasionally symptoms developing a few months post injury). In some instances, there is both a pleural effusion and/or a pulmonary infiltrate seen. Additionally, patients that have undergone cardiac surgery with subsequent post-cardiac injury syndrome often are found to have more elevated levels of anti-actin and actomyosin antibodies postoperatively. Finally, patients with DS or another post-cardiac injury syndrome tend to respond very well to anti-inflammatory treatments, and relapses are occasionally seen with withdrawal from steroids. 

Epidemiology

In the initial study examining DS in 1956, William Dressler suggested that the syndrome would occur in approximately 3% to 4% of patients with myocardial infarction (MI). With modern improvements in the management of acute myocardial infarctions, however, the condition is seen in much fewer patients. This may be attributable to successful interventions resulting in a reduction in the size of the infarct and subsequently damaged myocardium, thereby preventing the immune-mediated response seen in DS.

The risk of developing DS tends to be greater in post-MI patients who have suffered a larger infarction. Additionally, relapses are more likely to occur if a patient already has had a previous episode of DS. Additional predisposing factors for DS include

  1. viral infections
  2. surgeries involving greater myocardial damage
  3. younger age
  4. prior history of pericarditis
  5. prior treatment with prednisone
  6. B negative blood type
  7. and use of halothane anesthesia 

In terms of viral infections, a seasonal variation in the incidence of DS has been noted, where the condition is seen more commonly when the prevalence of a viral infection in the community is greatest too.  Though elevated viral titers are found in patients experiencing associated DS, viral components have not been isolated from the pericardium itself or the pleural effusion of these patients [8].

Surgeries that result in greater damage to the myocardium (e.g., aortic valve replacement) are more likely to result in DS than those that cause less myocardial injury (e.g., mitral valve replacement).  It is, however, important to note that DS can occur in patients that have undergone surgeries resulting in minimal trauma to the myocardium (e.g., needle puncture of a ventricle, CABG). Therefore, it is difficult to determine whether the extent of myocardial damage predicts the incidence of DS [9].

Finally, patients undergoing cardiac surgery that have a higher risk for developing DS are:

  1. younger age
  2. have a B negative blood type
  3. prior history of pericarditis or treatment with prednisone

The above should raise clinical suspicion and ractitioners should be cautious to note early signs of the condition (e.g., chest pain, persistent de novo fever) [10].

Pathophysiology

The exact cause of DS is unknown, though it is thought to be immune-mediated.  Antimyocardial antibodies have been shown to be elevated in the blood of patients with DS, but it is unclear whether these antibodies are the cause or occur as a result of the syndrome.  These antimyocardial antibodies are thought to target antigens that have become exposed through damage to the pericardium [11].  

Viruses that have been associated with DS include

  1. coxsackie B
  2. adenovirus
  3. cytomegalovirus

 These patients present with elevated levels of viral components [12]

History and Physical

Patients typically present with symptoms of DS 1 to 6 weeks following the initial damage to the pericardium. The most commonly encountered symptoms include

  1. fever
  2. malaise/generalized weakness,
  3. pleuritic chest pain
  4. irritability
  5. decreased appetite
  6. Palpitations/tachycardia
  7. dyspnea (with or without hypoxia)
  8. arthralgias

Though most patients tend to present with a temperature between 100.4 F and 102.2 F (measured orally), occasional reports of temperature as high as 104 F have been noted.  Not all patients will appear concomitantly ill, and the fever generally will subside within 2 to 3 weeks.

Children with DS may complain of chest pain that is worse with inspiration or while laying down. Emesis is often noted in children with DS that are at risk of impending cardiac tamponade.

On physical examination, patients with DS are often tachycardic with a pericardial friction rub heard on auscultation. This characteristic pericardial friction rub may disappear.  This can be secondary to either improvement in or worsening of accumulation of pericardial fluid, and therefore cannot be used predictively. Additionally, patients may present with pulsus paradoxicus (greater than 10mmHg decrease in blood pressure with inspiration, and decreased pulse amplitude palpated on the radial artery).

Finally, some patients with DS may exhibit signs of pneumonitis (e.g., a cough, decreased oxygen saturation, fever). The pulmonary component to symptoms can be minimal with no pulmonary complaints, ranging all the way to significant respiratory distress with large pulmonic effusions.   

Evaluation

The standard diagnostic procedure and most sensitive imaging study for evaluating a patient with suspected DS is an echocardiogram (echo). An echo will allow for evaluation of the pericardial fluid, if present, and help discern the exact cause of reduced cardiac output (i.e., determine whether truly DS or another condition such as congestive heart failure).  An echo will further allow for evaluation of ventricular contractility, in addition to assessment of the potential risk of cardiac tamponade (i.e., if cardiac chambers appear compressed by pericardial fluid). The more pericardial fluid that is accumulated, the easier it is to detect its presence by echocardiography [13].

Whilst definitive evaluation with formal echocardiogram is the gold standard, bedside cardiac ultrasound by a skilled emergency physician may be necessary.  These patients are at risk for cardiac tamponade, and care should NOT be delayed while awaiting formal echocardiography.  

If it is difficult to assess the posterior pericardium with an echo, cardiac magnetic resonance imaging (MRI) may be employed to determine whether there is an effusion present. In some instances, fluid collections may also become loculated. This is also more readily visualized with cardiac MRI than with echo [14].

Chest radiography (x-ray) may be employed if echocardiography is not available. A chest x-ray will reveal flattening of the costophrenic angles and enlargement of the cardiac silhouette as a result of both pleural and percardial effusions [15] [16].

An electrocardiograph (ECG) in a patient with DS will initially demonstrate global ST segment elevation and T-wave inversion, such as with pericarditis. Further inflammation of the myocardium will also result in ST segment elevations. Both electrical alternans (variation in amplitude or directionality of QRS from beat to beat) and/or a low voltage QRS also may be observed if there is a large volume pericardial effusion present. 

Blood cultures should be obtained early in the workup of DS as this will help differentiate between an inflammatory versus an infectious cause of the patient’s condition. In the case of true DS, blood cultures should be negative.

Laboratory studies that may help point toward a diagnosis of DS include an elevated white blood cell count (with a leftward shift) and elevated acute phase reactants (e.g., erythrocyte sedimentation rate and C-reactive protein). Additionally, there may be a high titer of anti-heart antibodies present in serology.

If it is possible, pericardial fluid (e.g., through a pericardial drain) should be examined for cell count, differential, cultures, Gram stain, cytology, total protein, and triglyceride levels [17]. 

Treatment / Management

Most patients with suspected DS are treated in an outpatient setting with close follow-up, unless the patient is hemodynamically unstable.  The approach typically involves NSAIDs (e.g., aspirin, ibuprofen, naproxen) which are tapered over a period of 4 to 6 weeks as the accumulated pericardial fluid diminishes. Patients who do not respond to NSAID therapy may be given a course of corticosteroids (e.g., prednisone) which are tapered over a 4-week period. [18].  Another potential treatment option is colchicine.  Some studies suggest that taking this before cardiac procedures may reduce the risk of DS, and its effectiveness once DS has developed is unclear

More severe cases of DS (i.e., symptoms that may indicate imminent cardiac tamponade or constrictive pericarditis) may require inpatient care involving pericardial drainage. Pericardiocentesis with subsequent catheter drainage (generally 24 to 48 hours) and concomitant initiation of anti-inflammatory treatment are considered the standard of care for patients with a significant pericardial effusion. If the effusion is global (surrounding the entire heart) and visible anteriorly (in front of the right ventricle), the subxiphoid approach for pericardiocentesis is recommended in addition to echocardiographic guidance. 

Recurrence of post-pericardiotomy syndrome, including DS, is common and relapses have been reported up to 1 year following the initial event. Some suggests that intravenous immunoglobulin therapy has some benefit in refractory cases, especially in children [19]. Remember the number one risk factor for developing DS is having had it before.

Differential Diagnosis

With presenting symptamology being so wide and varied, the differential diagnosis could be very broad as well.  However, with the more classic symptoms of chest pain, dyspnea, fever, malaise and tachycardia, there are certainly a few very important differentials.  As often most of these patients have been recently hospitalized and undergone some sort of procedure, they are at risk for several other potentially serious problems.  This list would incude the following:

  1. Pulmonary Embolus
  2. Sepsis
  3. Pneumonia
  4. Congestive Heart Failure
  5. Influenza
  6. Recurrent Cardiac injury (such as Acute MI/in-stent restenosis, or valve failure)
  7. Acute anemia with or without GI bleed
  8. Endocarditis
  9. Uremia

Secondary to this broad and potentially life threatening subset of other disease processes, the evaluation for DS, will often include evaluation for these other processes as well.

Treatment Planning

As above, the treatment options range from simple use of NSAIDs, with close out-patient cardiology follow up, to the need for emergent pericardiocentesis for those patients with hemodynamic compromise.  The majority of patients with DS are those patients who are non-toxic, without hemodynamic compromise, and often able to be safely discharged, once other potentially serious diagnoses have also safely been ruled out.

Prognosis

The prognosis for patients with DS is typically considered to be quite good.  Even those patients requiring pericardial drainage, usually have a favorable prognosis, but do have a increased risk for reaccumulation of fluid and subsequent need for repeat pericardiocentesis and adjustments to medication regimens.  If thereafter, constrictive pericarditis develops, the need for pericardial stripping may become evident.

Complications

The most serious potential complication from DS, is by far pericardial tamponade leading to risk of complete cardio-vascular collapse.  There is often a pericardial effusion with DS, and this fluid build up around the heart can lead to ineffective relaxtion and filling of the atrio-ventricular system by causing direct pressure and therefore affecting both diastolic filling and systolic squeeze.  Classic findings of tamponade include Becks triad:

  1. low blood pressure
  2. distended neck veins (JVD)
  3. muffled/distant heart tones

This is a true emergency and requires rapid action.  Delay in providing removal can lead to cardiac collapse and death.  As little as 200cc can cause tamponade depending upon how rapid the collection developed.  The potential space can hold up to 2 liters of fluid however this is quite rare.

Consultations

Early cardiology consultation in suspected DS is recommended.

Deterrence and Patient Education

In those patients being discharged, all should be made aware to return for a evaluation immediately, for signs of progression of effusion and for signs of developing infection (i.e., increased shortness of breath, increased pain, palpitations, dizziness/lightheadedness, fevers, altered mentation, and syncope).  Cardiology follow up should be arranged by the referring physician.

Enhancing Healthcare Team Outcomes

The diagnosis of Dressler syndrome is not easy and can be confused with many other cardiac disorders. Hence, it is best managed with a multidisciplinary team that includes a cardiac nurse, emergency department physician, cardiologist, radiologist and an intensivist.

Most patients with suspected DS are treated in an outpatient setting with close follow-up, unless the patient is hemodynamically unstable.  The approach typically involves NSAIDs (e.g., aspirin, ibuprofen, naproxen) which are tapered over a period of 4 to 6 weeks as the accumulated pericardial fluid diminishes. Patients who do not respond to NSAID therapy may be given a 1-week course of corticosteroids (e.g., prednisone) which are tapered over a 4-week period [18].

More severe cases of DS may require pericardial drainage by the cardiac surgeon or cardiologist.

The outlook for most patients with DS is excellent. However, the recovery may take 2-4 weeks.[20]

 


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Dressler Syndrome - Questions

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A 59-year-old was previously admitted to the intensive care unit for chest pain. At that time, ECG revealed Q waves and an ST depression in the anterior leads. His cardiac enzymes were elevated and he was treated with nitroglycerin and inotropic support for low blood pressure. He was discharged 7 days later and return to be seen in the emergency department 3 weeks later. His complaints are of low-grade fever, chest pain, nausea, and generalized malaise. Hemodynamics are within acceptable limits. He complained that his pain radiated to his neck. ECG revealed generalized ST-segment elevation. What is the most appropriate disposition?



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Which of the following can cause sterile fibrinous pericarditis?



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A 63-year-old male was admitted to the hospital with chest pain. An ECG revealed ST segment elevations and q waves in the anterior wall leads. Cardiac enzymes were elevated, and he was treated in the intensive care unit with heparin and nitroglycerin. His recovery was uneventful, and he was discharged home to be readmitted in 4 weeks for a cardiac catheterization. Three weeks after his myocardial infarction, he returns to the hospital complaining of a low-grade fever and chest pain on deep breathing. He says that the pain is not crushing and does not radiate, but is more centered around his mid-chest. He has had some associated neck pain and has general malaise. An ECG reveals non-specific ST elevations diffusely. Based upon the presumed diagnosis what should be done next?



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A 71-year-old male with a history of myocardial infarction three weeks ago presents complaining of pleuritic chest pain and is found to have a mild fever, a normal physical exam, and normal ECG and chest x-ray. He has no evidence of deep venous thrombosis. He has normal renal function but reports an allergy to NSAIDs having caused anaphylaxis in the past. He has diabetes mellitus who has had difficulty in the past with controlling his sugars when ill. He also reports that he used to be on warfarin but is not sure why. What treatment should be initiated for this patient?



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A 59-year-old male presents with crushing substernal chest pain of several hours duration that is worse when he breathes deeply or lies down. He is four weeks post percutaneous angioplasty for acute myocardial infarction. His exam reveals a systolic rub over the left lower sternal border but heart tones cannot be heard. EKG shows ST elevation in all leads. Heart rate is 119 bpm, blood pressure is 83/60 mmHg, and the temperature is 100.2 F. The patient seems to be slightly confused. Bedside echocardiogram was performed as seen below. Which of the following is likely to be the most useful initial therapy for this patient?

(Move Mouse on Image to Enlarge)
  • Image 6893 Not availableImage 6893 Not available
    Contributed by Brandon Barth, MD
Attributed To: Contributed by Brandon Barth, MD



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Which patient most likely has Dressler syndrome?



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A 48-year-old male presents to the emergency department four weeks after coronary artery bypass grafting (CABG). He is complaining of pleuritic chest pain and some palpitation sensation. He reports a subjective fever and malaise but has not documented a true fever. His vitals are all within acceptable limits except a heart rate of 105 bpm and a temperature of 100.3 F. On exam his is nontoxic smiling and talking in full sentences. He has clear lung fields, has no edema, no jugular venous distension, and heart sounds are normal except for a slight friction rub. His EKG demonstrates diffuse ST elevations without reciprocal changes. Which of the following medications is considered part of the first-line treatment for the suspected disease process?



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A 66-year-old female was admitted six months ago to the hospital for a porcine mitral valve replacement. She was discharged home three days later without complication. She followed up two months later for some atypical symptoms of sharp chest pain which resolved with ibuprofen. She now presents to the emergency department with pleuritic chest pain (worse with lying down), shortness of breath and a 100.4 F fever measured at home. Vital signs show a blood pressure of 121/70 mmHg, pulse 103, temperature 99.9 F, and respiratory rate 19 bpm. On exam, she is no obvious distress but has slight edema in her legs which she reports is unchanged since her discharge from the hospital six months ago. EKG reveals sinus tachycardia with a slightly shortened PR interval and borderline ST-segment changes diffusely, more noticeable in leads V1 and V2. Which of the following is the next best step in the management of this patient?



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A 68-year-old female presents with complaints of chest pain and malaise. She reports that the pain is sharp in nature and occurs while inhaling and exhaling. She has a history of mitral valve prolapse, and about forty-five days ago, she underwent an open mitral valve repair for severe regurgitation. An echocardiogram is performed and shows a mild pericardial effusion. Which of the following postoperative prophylactic treatment could have helped prevent this condition?



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Dressler Syndrome - References

References

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Repeated postpericardiotomy syndrome following a temporary transvenous pacemaker insertion, a permanent transvenous pacemaker insertion and surgical pericardiotomy., Sasaki A,Kobayashi H,Okubo T,Namatame Y,Yamashina A,, Japanese circulation journal, 2001 Apr     [PubMed]
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The postcardiac injury syndrome: case report and review of the literature., Wessman DE,Stafford CM,, Southern medical journal, 2006 Mar     [PubMed]
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Does pericardial drainage decrease the frequency of postpericardiotomy syndrome?, Desaulniers D,Gervais N,Rouleau J,, Canadian journal of surgery. Journal canadien de chirurgie, 1981 May     [PubMed]
Pericardial disease: diagnosis and management., Khandaker MH,Espinosa RE,Nishimura RA,Sinak LJ,Hayes SN,Melduni RM,Oh JK,, Mayo Clinic proceedings, 2010 Jun     [PubMed]
Recurrent pericarditis., Imazio M,Battaglia A,Gaido L,Gaita F,, La Revue de medecine interne, 2017 May     [PubMed]
Intravenous immunoglobulin therapy for refractory recurrent pericarditis., del Fresno MR,Peralta JE,Granados MÁ,Enríquez E,Domínguez-Pinilla N,de Inocencio J,, Pediatrics, 2014 Nov     [PubMed]
The effective treatment of postpericardiotomy syndrome after cardiac operations. A randomized placebo-controlled trial., Horneffer PJ,Miller RH,Pearson TA,Rykiel MF,Reitz BA,Gardner TJ,, The Journal of thoracic and cardiovascular surgery, 1990 Aug     [PubMed]
Kabukcu M,Demircioglu F,Yanik E,Basarici I,Ersel F, Pericardial tamponade and large pericardial effusions: causal factors and efficacy of percutaneous catheter drainage in 50 patients. Texas Heart Institute journal. 2004;     [PubMed]

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