What is the management and treatment of Dressler syndrome?

Management and Treatment of Dressler Syndrome

The cornerstone of Dressler syndrome management is anti-inflammatory therapy, with aspirin (500-1000 mg every 6-8 hours) as first-line treatment for most patients, while colchicine (0.5-0.6 mg once or twice daily) combined with acetaminophen is preferred in patients with recent coronary stenting. 1

Understanding Dressler Syndrome

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
• Features include fever, pericarditic/pleuritic chest pain, pericardial/pleural effusions, and elevated inflammatory markers
• Most commonly follows myocardial infarction, but can also occur after cardiac surgery, traumatic cardiac injury, percutaneous interventions, and even minor pericardial bleeding 1

Diagnostic Approach

Diagnosis requires at least two of the following five criteria following cardiac injury:

• Fever without alternative causes
• Pericarditic or pleuritic chest pain
• Pericardial or pleural rubs
• Evidence of pericardial effusion
• Pleural effusion with elevated inflammatory markers (CRP, ESR) 1

Additional diagnostic findings include:

• ECG: Diffuse concave ST-segment elevation and PR-segment depression
• Echocardiography: To detect pericardial effusion
• Exclusion of other causes of acute pleuritis 1, 2

Treatment Algorithm

First-Line Treatment

1. For most patients:

   • High-dose aspirin (500-1000 mg every 6-8 hours) until symptoms improve 1

2. For patients with recent coronary stenting:

   • Colchicine (0.5-0.6 mg once or twice daily) combined with acetaminophen (up to 2000 mg/day) 1, 3
   • This combination avoids bleeding risks associated with high-dose aspirin in patients on dual antiplatelet therapy 3

Second-Line Treatment

• Glucocorticoids (prednisone 0.25-0.5 mg/kg/day) for patients who fail to respond to first-line therapy 1
• Caution: Glucocorticoids should be used carefully in post-MI patients as they may impair myocardial healing

Duration of Treatment

• Initial treatment: Until symptoms resolve and inflammatory markers normalize
• Colchicine: Continue for 3 months to prevent recurrence 1
• Avoid premature discontinuation of anti-inflammatory therapy

Monitoring and Follow-up

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

Special Considerations and Pitfalls

1. Anticoagulation caution:

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

2. NSAIDs in post-MI patients:

   • Some NSAIDs may be potentially harmful for post-MI pericarditis 1

3. Recurrence management:

   • Long-term colchicine (0.5-0.6 mg daily) may be considered for recurrent cases 1

4. Differential diagnosis:

   • Important to differentiate from other causes of pleuritis, including malignancy
   • If malignancy has not manifested within 3 years, the effusion is generally considered benign 2

5. Changing epidemiology:

   • Incidence has decreased (<1%) in the era of primary percutaneous coronary intervention 1
   • Despite its rarity, it remains clinically important with potential for serious morbidity 4

The treatment approach has evolved with modern interventional cardiology. While high-dose aspirin was traditionally recommended based on pre-PCI era evidence, the combination of colchicine and acetaminophen has emerged as an effective alternative, particularly for patients who have undergone recent coronary stenting 3.