Dressler Syndrome

Article Author:
Ari Leib
Article Author (Archived):
Lisa Foris
Article Editor:
Karam Khaddour
Updated:
7/4/2019 9:02:04 AM
PubMed Link:
Dressler Syndrome

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 an interprofessional 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]


References

[1] Postcardiac injury syndrome., Jaworska-Wilczynska M,Abramczuk E,Hryniewiecki T,, Medical science monitor : international medical journal of experimental and clinical research, 2011 Nov     [PubMed PMID: 22037738]
[2] Uncommon presentation of postcardiac injury syndrome: acute pericarditis after percutaneous coronary intervention., Gungor B,Ucer E,Erdinler IC,, International journal of cardiology, 2008 Aug 1     [PubMed PMID: 17706808]
[3] Postpericardiotomy syndrome after permanent pacemaker implantation in children and young adults., Zeltser I,Rhodes LA,Tanel RE,Vetter VL,Gaynor JW,Spray TL,Cohen MI,, The Annals of thoracic surgery, 2004 Nov     [PubMed PMID: 15511456]
[4] 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 PMID: 11316136]
[5] Recurrent pericardial effusion after nonpenetrating chest trauma: report of two cases treated with adrenocortical steroids., GOODKIND MJ,BLOOMER WE,GOODYER AV,, The New England journal of medicine, 1960 Nov 3     [PubMed PMID: 13707022]
[6] Postpericardiotomy syndrome as a complication of percutaneous left ventricular puncture., Peter RH,Whalen RE,Orgain ES,McIntosh HD,, The American journal of cardiology, 1966 Jan     [PubMed PMID: 5900343]
[7] Contemporary features, risk factors, and prognosis of the post-pericardiotomy syndrome., Imazio M,Brucato A,Rovere ME,Gandino A,Cemin R,Ferrua S,Maestroni S,Barosi A,Simon C,Ferrazzi P,Belli R,Trinchero R,Spodick D,Adler Y,, The American journal of cardiology, 2011 Oct 15     [PubMed PMID: 21798503]
[8] Viral illness and the postpericardiotomy syndrome. A prospective study in children., Engle MA,Zabriskie JB,Senterfit LB,Gay WA Jr,O'Loughlin JE Jr,Ehlers KH,, Circulation, 1980 Dec     [PubMed PMID: 7438350]
[9] The postpericardiotomy syndrome then and now., Engle MA,Gay WA Jr,Kaminsky ME,Zabriskie JB,Senterfit LB,, Current problems in cardiology, 1978 May     [PubMed PMID: 122753]
[10] The postpericardiotomy and similar syndromes., Engle MA,Klein AA,Hepner S,Ehlers KH,, Cardiovascular clinics, 1976     [PubMed PMID: 1000538]
[11] Heart-reactive antibody, viral illness, and the postpericardiotomy syndrome. Correlates of a triple-blind, prospective study., Engle MA,Zabriskie JB,Senterfit LB,, Transactions of the American Clinical and Climatological Association, 1976     [PubMed PMID: 785768]
[12] Postoperative pericardial effusion and its relation to postpericardiotomy syndrome., Clapp SK,Garson A Jr,Gutgesell HP,Cooley DA,McNamara DG,, Pediatrics, 1980 Oct     [PubMed PMID: 7432845]
[13] The postcardiac injury syndrome: case report and review of the literature., Wessman DE,Stafford CM,, Southern medical journal, 2006 Mar     [PubMed PMID: 16553111]
[14] Cardiac tamponade complicating postpericardiotomy syndrome., Scarfone RJ,Donoghue AJ,Alessandrini EA,, Pediatric emergency care, 2003 Aug     [PubMed PMID: 12972828]
[15] 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 PMID: 7016286]
[16] 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 PMID: 20511488]
[17] Recurrent pericarditis., Imazio M,Battaglia A,Gaido L,Gaita F,, La Revue de medecine interne, 2017 May     [PubMed PMID: 28185680]
[18] 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 PMID: 2200931]
[19] 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 PMID: 25287461]
[20] 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 PMID: 15745292]