Management of Dressler Syndrome
Anti-inflammatory therapy is the cornerstone of management for Dressler syndrome, with aspirin as first-line treatment, while colchicine is preferred in patients with recent coronary stenting. 1
Pathophysiology and Clinical Context
Dressler syndrome is an autoimmune response triggered by myocardial injury, characterized by:
- Pericardial inflammation with potential pleural involvement
- Typically occurs 1-6 weeks after cardiac injury (most commonly myocardial infarction)
- Features include fever, pericarditic/pleuritic chest pain, pericardial/pleural effusions, and elevated inflammatory markers
- Has become rare (<1%) in the era of primary percutaneous coronary intervention 1
Treatment Algorithm
First-Line Therapy
For most patients: High-dose aspirin (650-1000 mg every 6-8 hours) 1
- Provides both anti-inflammatory and analgesic effects
- Duration: 1-2 weeks, followed by tapering over 2-3 weeks based on symptom resolution
For patients with recent coronary stenting: Colchicine (0.5-0.6 mg twice daily) 1, 2
- Preferred when bleeding and thrombotic concerns exist with high-dose aspirin
- Can be combined with acetaminophen (up to 2000 mg/day) for symptom relief 2
- Duration: 3 months for first episode, 6 months for recurrences
Second-Line Therapy
- Glucocorticoids (prednisone 0.25-0.5 mg/kg/day)
- Reserved for patients who fail to respond to first-line therapy
- Should be used cautiously in post-MI patients as they may impair myocardial healing 1
- Taper slowly over weeks to months to prevent recurrence
Adjunctive Measures
- Pain management: Acetaminophen can be used for pain control
- Treatment of effusions:
- Pericardiocentesis only if hemodynamically significant effusion
- Thoracentesis for symptomatic pleural effusions
Special Considerations
Monitoring and Follow-up
- Serial echocardiography to monitor pericardial effusion
- Regular assessment of inflammatory markers (CRP, ESR)
- ECG monitoring for evolving changes
Recurrence Prevention
- Long-term colchicine (0.5-0.6 mg daily) may be considered for recurrent cases
- Avoid premature discontinuation of anti-inflammatory therapy
Cautions
- NSAIDs: May be potentially harmful for treatment of post-MI pericarditis 1
- Anticoagulation: Use with caution in patients with pericardial effusion due to risk of tamponade
- Steroid therapy: In patients with post-MI Dressler syndrome, consult with cardiologist before initiating due to potential risk of myocardial rupture 3
Treatment Efficacy
A case report demonstrated successful treatment of Dressler syndrome with combination therapy of colchicine (0.5 mg/day) and acetaminophen (2000 mg/day) in a patient who had undergone recent coronary stenting, with clinical improvement allowing discharge 9 days after treatment initiation 2.
In another case, a 68-year-old woman with late-onset Dressler syndrome (9 weeks post-ACS) responded well to a 7-day treatment with ibuprofen 4.
The management approach should be guided by the patient's specific clinical scenario, particularly considering the timing relative to the cardiac injury and any recent interventions such as coronary stenting.