What are the diagnostic criteria and management options for Dressler's syndrome?

Dressler's Syndrome: Diagnostic Criteria and Management

Dressler's syndrome is diagnosed when a patient develops pericarditis 1-6 weeks after cardiac injury, with at least two of the following criteria: fever without alternative cause, pericarditic/pleuritic chest pain, pericardial/pleural rubs, evidence of pericardial effusion, or pleural effusion with elevated inflammatory markers. 1

Diagnostic Criteria

Clinical Presentation

• Timing: Typically occurs 1-6 weeks after cardiac injury 1, 2
• Required symptoms (at least 2 of the following):
  • Fever without alternative causes
  • Pericarditic or pleuritic chest pain
  • Pericardial or pleural rubs on examination
  • Evidence of pericardial effusion
  • Pleural effusion with elevated inflammatory markers (CRP, ESR) 1

Precipitating Factors

• Most commonly follows myocardial infarction (especially transmural) 3
• Other causes:
  • Cardiac surgery 4
  • Traumatic cardiac injury
  • Percutaneous coronary interventions
  • Minor pericardial bleeding 1

Diagnostic Tests

1. ECG findings: Diffuse concave ST-segment elevation and PR-segment depression 3, 4
2. Echocardiography: To detect pericardial effusion 3, 5
3. Laboratory tests: Elevated inflammatory markers (CRP, ESR), possible eosinophilia 6
4. Cardiac MRI: Can show features of pericarditis when diagnosis is uncertain 2

Management Options

First-Line Treatment

• High-dose aspirin: 500-1000 mg every 6-8 hours until symptoms improve 3
  • Caution: In patients with recent coronary stenting, consider alternative options due to bleeding risk 1

Alternative First-Line Options

• Colchicine: 0.5-0.6 mg once or twice daily for 3 months 3, 1
  • Preferred in patients with recent coronary stenting
  • Can be combined with acetaminophen (up to 2000 mg/day) for symptom relief 1

Second-Line Treatment

• Glucocorticoids: Prednisone 0.25-0.5 mg/kg/day 1
  • Reserved for patients who fail to respond to first-line therapy
  • Use with caution in post-MI patients as they may impair myocardial healing and increase risk of myocardial rupture 1

Monitoring

• Serial echocardiography to monitor pericardial effusion
• Regular assessment of inflammatory markers (CRP, ESR)
• ECG monitoring for evolving changes 1

Special Considerations

Recurrent Cases

• Long-term colchicine (0.5-0.6 mg daily) may be considered 1
• Avoid premature discontinuation of anti-inflammatory therapy

Anticoagulation

• Use with caution in patients with pericardial effusion due to risk of tamponade 1

Declining Incidence

• Dressler's syndrome has become rare (<1%) in the era of primary percutaneous coronary intervention 1
• May be underdiagnosed in clinical practice 4

Complications

• Pericardial effusion with potential cardiac tamponade 5
• Pleural effusions 4
• Atrial fibrillation 2

Recognizing Dressler's syndrome promptly is essential as appropriate anti-inflammatory therapy can lead to rapid clinical improvement and prevent complications.