Background

• Dressler syndrome, also known as post-myocardial infarction syndrome, is a rare condition characterized by pericardial inflammation, the sac-like membrane surrounding the heart. It typically occurs following a heart attack (myocardial infarction) or cardiac surgery. Dressler syndrome is considered an autoimmune response triggered by the release of antigens from damaged cardiac tissue, which leads to an immune-mediated inflammatory response. 
• The name “Dressler syndrome” is derived from Dr. William Dressler, who first described the condition in 1956. The syndrome typically develops several weeks to months after the initial cardiac event or surgery, although it can occur earlier or later. 
• Dressler syndrome is uncommon due to advances in early treatment of heart attacks and the decreased use of open-heart surgery. However, it remains an important condition to recognize and manage appropriately. 
• The main features of Dressler syndrome include chest pain, fever, and pericarditis (inflammation of the pericardium). Additional symptoms may include fatigue, malaise, pleuritic pain (pain worsened by deep breathing or coughing), and occasionally, the accumulation of fluid in the pericardial space (pericardial effusion).  
• The management of Dressler syndrome involves a combination of supportive care and anti-inflammatory treatment. Nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine are commonly used to relieve pain and reduce inflammation. 

Epidemiology

• Incidence: The exact incidence of Dressler syndrome is difficult to determine due to variations in reporting and diagnostic criteria. However, it is considered a rare condition. 
• Timing: Dressler syndrome typically develops within a few weeks to months after a myocardial infarction (heart attack) or cardiac surgery.  
• Occurrence: The incidence of Dressler syndrome has decreased over the years, likely due to improved early management of myocardial infarction and the decreased use of open-heart surgery. 
• Risk Factors: Factors that may have an increased risk of developing Dressler syndrome include a history of myocardial infarction, pericardial injury, previous cardiac surgery, and delayed treatment of the initial cardiac event. 
• Age and Gender: Dressler syndrome can affect individuals of any age, but it is commonly seen in middle-aged and older adults. There is no significant gender predilection, and both men and women can be affected. 

Anatomy

Pathophysiology

• The pathophysiology of Dressler syndrome, also known as post-myocardial infarction syndrome, involves an autoimmune-mediated inflammatory response. The syndrome typically occurs weeks to months after an acute myocardial infarction (heart attack) or cardiac surgery. The exact mechanism of action is not well known, but it is believed to be the release of cardiac antigens, leading to an immune response. 
• The inflammatory process involves the activation of immune cells, particularly T lymphocytes and macrophages, which infiltrate the pericardium. This immune response results in the formation of immune complexes, release of pro-inflammatory cytokines, and recruitment of inflammatory cells. The inflammation leads to the characteristic symptoms of Dressler syndrome, including chest pain, fever, pericardial effusion, and inflammation of the pericardium. 
• The immune-mediated inflammation can also contribute to the development of fibrinous adhesions between the pericardial layers, leading to the formation of a fibrous pericardial scar. This scar tissue can cause further complications such as constrictive pericarditis, a condition characterized by the stiffening and thickening of the pericardium, impairing cardiac function. 

Etiology

• Myocardial Injury: Dressler syndrome typically occurs from myocardial injury, such as a heart attack (myocardial infarction) or cardiac surgery. The exact mechanism by which the injury leads to Dressler syndrome is not fully understood. 
• Autoimmune Response: Following myocardial injury, it is believed that the release of cardiac antigens triggers an autoimmune response in susceptible individuals. The immune system mistakenly recognizes these cardiac antigens as foreign and mounts an immune response. 
• Inflammatory Process: The autoimmune response leads to inflammation in the pericardium, the outer lining of the heart. The inflammation is characterized by the infiltration of immune cells, including lymphocytes and macrophages, into the pericardium. 
• Immune Complex Formation: In Dressler syndrome, immune complexes consisting of antibodies and antigens are formed. These immune complexes further contribute to the inflammatory process and can activate the complement system. 
• Delayed Hypersensitivity: Dressler syndrome is also thought to involve a delayed hypersensitivity reaction, where T-cells recognize cardiac antigens and initiate an immune response. This immune response leads to the production of cytokines and inflammatory mediators. 

Genetics

Prognostic Factors

• Time of Onset: The timing of onset of Dressler syndrome after the initial myocardial injury can be an important prognostic factor. Early onset within a few weeks after the injury is typically associated with a more severe clinical course. 
• Severity of Symptoms: The severity of symptoms, such as chest pain, fever, and pericardial effusion, can influence the prognosis of Dressler syndrome.  
• Complications: The development of complications, such as recurrent pericardial effusion, cardiac tamponade, or constrictive pericarditis, can impact the prognosis of Dressler syndrome. These complications may require additional interventions or surgical procedures and can affect long-term outcomes. 
• Underlying Cardiac Health: The overall cardiac health and function of the patient, including the presence of underlying heart disease or previous myocardial injury, can influence the prognosis of Dressler syndrome. Patients with pre-existing cardiac conditions may have a higher risk of complications. 
• Response to Treatment: The response to appropriate treatment, such as anti-inflammatory medications, corticosteroids, or pericardial drainage, can also impact the prognosis. Prompt and effective management of the inflammatory process can lead to improved outcomes. 

Clinical History

Physical Examination

General Appearance: 

• Patients with Dressler syndrome may appear acutely ill or in distress due to chest pain or respiratory symptoms. 
• They may exhibit signs of discomfort, such as grimacing or guarding the chest. 

Vital Signs: 

• Heart Rate: Tachycardia (elevated heart rate) may be present due to the inflammatory response and pain. 
• Blood Pressure: Hypertension (elevated blood pressure) can occur in response to the increased sympathetic activity. 

Chest Examination: 

• Inspection: The chest may appear normal or show signs of discomfort, such as shallow breathing or splinting. 
• Palpation: Tenderness or discomfort may be elicited upon palpation of the chest wall. 
• Auscultation: Heart sounds may reveal a pericardial friction rub, which is a high-pitched scratching or grating sound heard during the cardiac cycle. This sound occurs due to the rubbing of the inflamed pericardial layers against each other. 

Respiratory Examination: 

• Auscultation: Lung sounds should be assessed to evaluate for the presence of pleural effusion or any signs of respiratory compromise. 

Extremities: 

• Edema: Peripheral edema may be present in some cases, particularly if there is associated heart failure. 

Age group

Associated comorbidity

• Dressler syndrome is most associated with myocardial infarction (heart attack) but can also occur after other forms of myocardial injury, such as cardiac surgery or trauma. 
• Patients with myocardial infarction or cardiac surgery are at higher risk of developing Dressler syndrome. 
• The onset of Dressler syndrome often follows a period of relative rest or reduced activity following a myocardial injury. 
• The condition may develop a few weeks to months after the initial insult, during the recovery phase.

Associated activity

Acuity of presentation

Dressler syndrome typically presents as a constellation of symptoms and signs, including: 

• Chest pain: Patients may experience persistent or recurrent chest pain, which can be sharp or pleuritic in nature. 
• Fever: Low-grade fever is common in Dressler syndrome. 
• Pericardial Effusion: Accumulation of fluid in pericardial sac can cause symptoms like SOB, cough, or a feeling of heaviness in the chest. 
• Pericarditis: Inflammation of the pericardium, the outer lining of the heart, can lead to characteristic chest pain that worsens with deep breathing. 

Differential Diagnoses

Acute Myocardial Infarction (AMI): 

• Dressler syndrome can mimic the symptoms and signs of an acute myocardial infarction, including chest pain, elevated cardiac enzymes, and electrocardiogram (ECG) changes. However, in Dressler syndrome, the symptoms typically occur several weeks after the initial myocardial infarction. 

Pulmonary Embolism: 

• Pulmonary embolism can present with similar symptoms to Dressler syndrome, such as pleuritic chest pain and shortness of breath. Imaging studies, such as a computed tomography pulmonary angiogram (CTPA), can help differentiate between the two conditions. 

Pneumonia: 

• Pneumonia can cause symptoms such as fever, cough, and chest pain, which can overlap with Dressler syndrome. Chest imaging, like a chest X-ray or computed tomography (CT) scan, can help identify the presence of pneumonia. 

Pericarditis: 

• Pericarditis itself can mimic the symptoms of Dressler syndrome. Differentiating between the two may require careful assessment of the timing of symptoms and clinical history. 

Postoperative Complications: 

• Dressler syndrome can occur following cardiac surgery, and its symptoms may overlap with postoperative complications, such as wound infection or atelectasis. Evaluation of surgical incisions, laboratory values, and imaging studies can help differentiate Dressler syndrome from surgical complications. 

Pleurisy: 

• Pleurisy, an inflammation of the pleural membranes, can cause chest pain like Dressler syndrome. Physical examination findings, chest imaging, and other diagnostic tests can aid in differentiating between the two conditions. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

• Bed rest: Patients with Dressler syndrome may benefit from adequate rest to reduce myocardial workload and promote healing. 
• Pain management: non-steroidal anti-inflammatory drugs (NSAIDs) or analgesics can be used to alleviate chest pain and discomfort. 

• Non-steroidal anti-inflammatory drugs (NSAIDs): Drugs such as aspirin or ibuprofen are commonly used to reduce inflammation and relieve pain. They can be effective in managing Dressler syndrome. 
• Corticosteroids: In severe cases or when NSAIDs are contraindicated, corticosteroids like prednisone may be prescribed to suppress the immune response and reduce inflammation. 

Pericardiocentesis: In rare cases, if Dressler syndrome leads to significant pericardial effusion causing cardiac tamponade, a procedure called pericardiocentesis may be performed. It involves the insertion of a needle or catheter into the pericardial space to drain the excess fluid. 

• Acute phase: During the acute phase, the focus is on managing symptoms, providing pain relief, and reducing inflammation. NSAIDs or corticosteroids may be prescribed. 
• Subacute phase: As symptoms improve, medications may be gradually tapered off. Close monitoring of symptoms and regular follow-up visits are important to assess the patient’s progress. 
• Chronic phase: Long-term management involves regular monitoring of the patient’s cardiac health and addressing any underlying conditions that contribute to the development of Dressler syndrome. 

Medication

Future Trends

Media Gallary

References