What is Dressler Syndrome (Postmyocardial Infarction Syndrome)?
Dressler syndrome, or post-heart attack syndrome, is a type of inflammation of the tissue around the heart, possibly with fluid buildup, caused by damage to the heart or surrounding tissues. Although it’s not very common, it should be taken into account if someone continues to feel unwell or tired after a heart attack or heart surgery. This is especially the case if these symptoms persist more than two weeks after the event.
What Causes Dressler Syndrome (Postmyocardial Infarction Syndrome)?
Pericarditis is a condition where the pericardium (the protective bag around the heart) becomes irritated and inflamed. Usually, this bag has about 15 to 50mL of pericardial fluid, which is a type of plasma from your blood.
Dressler syndrome is one of several conditions known as post-cardiac injury syndromes. These conditions are related to various heart problems or treatments involving the heart. They include:
1. Postpericardiotomy syndrome, which happens after heart surgery.
2. Post-traumatic pericarditis, caused by a serious injury to the heart.
3. Various conditions resulting from interventions, such as heart procedures, inserting a pacemaker lead, or using radiofrequency ablation (a treatment using heat to destroy abnormal heart cells).
Each of these conditions represents a different case where the heart or its surrounding areas have been harmed and responded with inflammation. They can vary from simple pericarditis to more complex cases where there can be inflammation in the lining of the lungs or heart, an emergency situation where fluid builds up around the heart, or large amounts of fluid in the lung area.
The precise cause of Dressler syndrome is not clear, but it seems to involve some kind of initial damage to the cells lining the pericardium (the sac around the heart). When there is also blood in the pericardial space (between the sac and the heart), it can trigger an immune response. This leads to an immune reaction in the pericardium, the pleura (the sac that encases the lungs), and the lungs themselves which causes inflammation.
This theory is backed up by several observations. One is the delay period between the time of the heart injury and the onset of post-cardiac injury syndromes, which can be from a few days to up to 6 weeks post-injury. In some cases, symptoms can even develop a few months after the injury. Sometimes, these conditions can cause fluid to build up in the lungs or lung inflammation. Moreover, patients who have had heart surgery and subsequently developed a post-cardiac injury syndrome often show heightened levels of certain antibodies, which are proteins that fight infections. Moreover, patients with Dressler syndrome or another post-cardiac injury syndrome generally respond well to anti-inflammatory treatments, though sometimes symptoms can return after they stop using steroids.
Risk Factors and Frequency for Dressler Syndrome (Postmyocardial Infarction Syndrome)
The Dressler syndrome, initially studied by William Dressler in 1956, used to be seen in around 3% to 4% of heart attack patients. However, thanks to improvements in heart attack treatments, the condition has become less common. This is likely because treatments today can reduce the size of the damaged heart tissue, which helps prevent the immune response that results in Dressler syndrome.
The risk of Dressler syndrome is higher in heart attack patients who’ve had extensive heart tissue damage. Recurrences of the condition are also more prevalent in patients who’ve had Dressler syndrome before. Moreover, there are certain factors that can increase the likelihood of Dressler syndrome as well:
- Viral infections
- Surgeries that cause serious heart tissue damage
- Younger age
- Previous pericarditis (inflammation of the heart lining)
- Prior treatment with a drug called prednisone
- B negative blood type
- Use of halothane anesthesia
The incidence of Dressler syndrome seems to be higher during periods when viral infections are more common in the general population. However, there’s not enough evidence to directly attribute Dressler syndrome to these infections.
Surgeries that do more damage to the heart tissue, like aortic valve replacements, are more likely to result in Dressler syndrome than those that cause less heart tissue damage, like mitral valve replacements. But it’s hard to predict Dressler syndrome based on the extent of heart tissue damage alone. Even surgeries that result in minor heart tissue trauma can potentially cause Dressler syndrome.
Lastly, among patients who’ve undergone heart surgery, those at a higher risk of developing Dressler syndrome are typically younger, have a B-negative blood type, and have a previous history of pericarditis or prednisone treatment. Medical practitioners should watch out for early signs of the condition in these patients, like chest pain or consistent fever.
Signs and Symptoms of Dressler Syndrome (Postmyocardial Infarction Syndrome)
Dressler syndrome is a condition that usually appears 1 to 6 weeks after your pericardium, which is a thin sac surrounding your heart, gets damaged. The common symptoms include:
- Fever
- Feeling weak or tired
- Chest pain that gets worse with deep breaths
- Irritability
- Loss of appetite
- Faster heart rate
- Shortness of breath, with or without low oxygen levels
- Joint pain
Although patients often have a temperature between 100.4 F and 102.2 F, there have been cases with fever as high as 104 F. Not everyone with Dressler syndrome will look severely sick, and the fever usually goes away within 2 to 3 weeks.
Children with Dressler syndrome may report chest pain that gets worse when taking deep breaths or lying down. If they vomit, there could be a risk of cardiac tamponade, which is a serious condition where fluid builds up around the heart.
During a physical check-up, a doctor may find that a patient with Dressler syndrome has a fast heart rate. They may hear an unusual sound called a pericardial friction rub when listening to the heart. This sound might disappear over time depending on whether the fluid around the pericardium improves or worsens, so its absence doesn’t necessarily indicate how the condition will progress.
Some patients may also experience a drop in blood pressure and pulse when taking a deep breath, which is known as pulsus paradoxus.
In some cases, Dressler syndrome might also lead to signs of lung inflammation, such as coughing, decreased oxygen levels, and fever. The severity of these lung-related symptoms can vary a lot, with some patients having no lung complaints while others experience serious respiratory distress due to a large amount of fluid in the lungs.
Testing for Dressler Syndrome (Postmyocardial Infarction Syndrome)
If a doctor suspects a patient might have Dressler syndrome, they usually perform an echocardiogram. This is a type of ultrasound scan that allows the doctor to see if there is fluid around the heart and to evaluate the heart’s function. This test helps distinguish Dressler syndrome from other conditions that could lower heart function, like heart failure. It also helps them assess the risk of a dangerous condition known as cardiac tamponade, which can occur if fluid starts squeezing the heart.
If a more detailed examination is needed quickly, an emergency room doctor might perform a bedside cardiac ultrasound. This can be crucial as individuals with Dressler syndrome are at risk of cardiac tamponade, which shouldn’t be postponed while waiting for a full echocardiogram.
Sometimes, the liquid in the back of the heart can be hard to assess with an echocardiogram. Under these circumstances, a cardiac magnetic resonance imaging (MRI) scan might be used. This can also help to identify whether the fluid has formed pockets, which can be easier to spot on an MRI than on an echocardiogram.
If an echocardiogram isn’t available, a chest X-ray might be used. This can show if the heart size changes or if the spaces between the lungs and chest wall are unusual due to fluid in both the area around the heart and the lungs.
An electrocardiograph (ECG) may also be used. This records the electrical activity of the heart and can show particular patterns associated with Dressler syndrome. These include changes in the pattern of the heart traces (ST-segment elevation, T-wave inversion), variations in the heart’s electrical signals or decreased electrical signals if there is too much fluid around the heart.
To help diagnose Dressler syndrome, doctors may take blood samples to culture. This is to see if an infection might be causing the patient’s symptoms. In actual Dressler syndrome cases, these cultures should not show any bacteria.
Other useful lab tests can include a white blood cell count (which may be high) and measurements of inflammation markers like erythrocyte sedimentation rate and C-reactive protein. The presence of heart cell antibodies in the blood can also be informative.
If doable, a sample of the fluid around the heart should be tested to provide additional information, checking for cell types, bacteria, protein levels, and triglycerides.
Treatment Options for Dressler Syndrome (Postmyocardial Infarction Syndrome)
Most people with suspected Dressler syndrome, a condition typically involving heart inflammation after heart surgery, are usually treated outside of a hospital. However, they need to be checked regularly, especially if their condition worsens. The typical treatment is with non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, or naproxen, which are gradually reduced over 4 to 6 weeks as the fluid around the heart decreases. For those who don’t respond to NSAIDs, corticosteroids, like prednisone, may be administered and gradually reduced over a month. An additional potential treatment is a medicine called colchicine. Some research suggests using colchicine before heart procedures could lower the risk of developing Dressler syndrome, but it’s unclear how effective it is once Dressler syndrome has already developed.
More severe cases of Dressler syndrome may require in-hospital treatment, which can involve draining the fluid surrounding the heart, a procedure known as pericardiocentesis. This is usually standard care for patients with a lot of fluid around their heart, and this process generally lasts 24 to 48 hours. If the fluid surrounds the entire heart and is visible at the front of the heart’s right ventricle, pericardiocentesis is recommended in addition to an ultrasound of the heart.
Recurrences of Dressler syndrome are common, and patients may experience symptoms up to a year after the initial event. Some experts suggest that intravenous immunoglobulin therapy (infusion of antibodies) might be beneficial in stubborn cases, especially in children. It’s important to remember that those who’ve had Dressler syndrome before are at the highest risk of developing it again.
What else can Dressler Syndrome (Postmyocardial Infarction Syndrome) be?
Since symptoms can vary greatly, there can be a wide range of possible conditions that may be responsible for the patient’s health issue. Common symptoms such as chest pain, difficulty breathing, fever, fatigue, and rapid heartbeat could point to several major conditions. This is especially true if the patient has recently been in the hospital or had a procedure, as they could be at risk for several other serious complications. These could include:
- Blood clot in the lungs (Pulmonary embolus)
- Bodywide infection (Sepsis)
- Lung infection (Pneumonia)
- Heart not pumping properly (Congestive heart failure)
- Flu (Influenza)
- Repeat of heart issues (such as a heart attack, problems with stents, or valve failure)
- Low red blood cell count (Acute anemia), possibly with bleeding in the digestive tract
- Heart infection (Endocarditis)
- Build-up of waste products in the blood (Uremia)
Because all these conditions are serious, and could also be life-threatening, doctors will usually check for these issues when trying to diagnose a condition called Dressler syndrome.
What to expect with Dressler Syndrome (Postmyocardial Infarction Syndrome)
The outlook for patients with Dressler syndrome is usually very positive. Even those who need a procedure to drain fluid from the heart lining typically have a good recovery rate. However, there’s an increased chance that the fluid will build up again, possibly leading to another draining procedure and changes to their medication plans. If a condition called constrictive pericarditis develops, which causes the heart lining to become stiff and thickened, they might need a procedure to remove this lining.
Possible Complications When Diagnosed with Dressler Syndrome (Postmyocardial Infarction Syndrome)
The most dangerous complication that can occur with Dressler syndrome is pericardial tamponade. This condition can cause a complete cardiovascular collapse. Dressler syndrome often leads to pericardial effusion, which is fluid build-up around the heart. This can affect the heart’s ability to relax and fill properly because it creates pressure, impacting both the heart’s ability to fill with blood (diastolic filling) and to squeeze to pump out blood (systolic squeeze).
The typical signs of tamponade include what’s known as Beck’s triad:
- Low blood pressure
- Swollen neck veins (also known as jugular venous distension)
- Faint heart sounds
This is a serious and urgent situation that needs to be addressed immediately. If the removal of the fluid is delayed, it can result in a cardiac collapse and even death. As little as 200 cc of fluid can lead to tamponade, depending on how quickly it accumulates. This area can hold up to 2 liters of fluid, but such cases are quite rare.
Preventing Dressler Syndrome (Postmyocardial Infarction Syndrome)
If you are getting discharged from the hospital, you should be fully aware of the need to come back for a check-up immediately if you start to notice signs of Dressler syndrome. These signs could include increasing difficulty in breathing, increased pain, heart palpitations, feeling dizzy or lightheaded, fevers, altered mental status, and fainting. A follow-up with a heart specialist (cardiologist) should be organized by your primary care physician.
