Dressler Syndrome

Dressler syndrome is a delayed pericarditis, with or without pleural effusion, after myocardial injury. It results from an autoimmune response to myocardial antigens.

Occurs 1 to 8 weeks after myocardial infarction, cardiac surgery (postpericardiotomy syndrome), trauma or cardiac procedures such as ablation and pacemaker lead perforation.

Incidence after infarction is now under 1%, owing to early reperfusion. After cardiac surgery it is 10 to 20%.

Distinguished from early infarct related pericarditis, which occurs in the first 1 to 4 days.

Complications: pericardial effusion, tamponade (uncommon), recurrence in 15 to 30%, constrictive pericarditis (rare).

• Pleuritic chest pain relieved by sitting forward, worse supine.
• Fever, malaise, arthralgia.
• Pericardial friction rub, pleural rub, dyspnoea.
• Tamponade features: hypotension, raised venous pressure, pulsus paradoxus.
• Differential diagnosis includes recurrent infarction, pulmonary embolism, pneumonia, aortic dissection and sepsis.

• ECG: diffuse concave ST elevation and PR depression, evolving to T wave inversion.
• Raised CRP, ESR and leucocytosis. Troponin may rise modestly (myopericarditis).
• Echocardiography for effusion and tamponade physiology. Chest radiograph for effusion and enlarged cardiac silhouette.
• Cardiac MRI shows pericardial late gadolinium enhancement.
• Exclude infection, reinfarction and ventricular rupture (pseudoaneurysm).

• Aspirin 650 mg every 6 to 8 hours (or 500 to 1000 mg every 8 hours) for 1 to 2 weeks, tapering over 2 to 4 weeks. Preferred after infarction, since other NSAIDs and steroids may impair scar healing.
• Colchicine 0.5 mg twice daily (0.5 mg once daily if under 70 kg) for 3 months, reduces recurrence by about 50%. Reduce dose in renal impairment and avoid with strong CYP3A4 or P glycoprotein inhibitors.
• Add a proton pump inhibitor for gastric protection.
• Ibuprofen 600 mg every 8 hours may be used after cardiac surgery or when infarction is not recent.
• Prednisolone 0.2 to 0.5 mg/kg daily with taper only for refractory cases or when NSAIDs are contraindicated.
• Symptomatic or large effusions: pericardiocentesis under echo guidance for tamponade. Pericardial window for recurrent effusions.
• Recurrent disease: continue colchicine, consider anakinra 100 mg SC daily or rilonacept in steroid dependent cases.
• Anticoagulation poses a risk of haemopericardium, so reassess ongoing need.
• Restrict strenuous exercise until symptoms and markers normalise.