Is a patient with Dressler syndrome a candidate for Coronary Artery Bypass Grafting (CABG)?

Fitness for CABG in Patients with Dressler Syndrome

Patients with Dressler syndrome can undergo CABG if the underlying coronary anatomy warrants surgical revascularization, but surgery should be delayed until the acute inflammatory phase has resolved and the patient has been stabilized with appropriate anti-inflammatory treatment.

Understanding Dressler Syndrome

Dressler syndrome (post-myocardial infarction syndrome) is characterized by:

• Pericardial inflammation with potential pericardial effusion
• Pleuritic chest pain
• Elevated inflammatory markers
• Typically occurs 1-6 weeks after myocardial injury 1, 2
• May present with fever, pericarditis, pleuritis, and serologic changes 3

CABG Decision Algorithm for Patients with Dressler Syndrome

Step 1: Assess Coronary Anatomy and Indications for CABG

First, determine if the patient meets standard indications for CABG:

• Strong indications (Class I) 4, 5:

  • Significant left main coronary artery stenosis (>50%)
  • Left main equivalent disease (≥70% stenosis of proximal LAD and proximal left circumflex)
  • Three-vessel disease (especially with reduced LVEF <50%)
  • Two-vessel disease with significant proximal LAD stenosis and either EF <50% or demonstrable ischemia

• Reasonable indications (Class IIa) 4, 5:

  • Proximal LAD stenosis with 1-vessel disease
  • Complex 3-vessel CAD (SYNTAX score >22)

Step 2: Evaluate Dressler Syndrome Status and Risk

Assess the current status of Dressler syndrome:

• Active phase (contraindication to immediate CABG):

  • Presence of significant pericardial effusion
  • Fever >38°C
  • Elevated inflammatory markers (ESR, CRP)
  • Pleuritic chest pain
  • Evidence of pericardial inflammation on imaging

• Risk factors to consider:

  • Potential for pericardial tamponade
  • Increased bleeding risk if on anti-inflammatory medications
  • Increased risk of postoperative complications due to inflammatory state

Step 3: Management Before Considering CABG

1. Treat Dressler syndrome first 6, 2:

   • Anti-inflammatory therapy with colchicine (0.5-1.0 mg/day)
   • Consider NSAIDs (ibuprofen) or acetaminophen
   • In severe cases, corticosteroids may be necessary

2. Monitor for resolution:

   • Clinical improvement (resolution of fever, chest pain)
   • Reduction in inflammatory markers
   • Resolution or significant reduction of pericardial effusion on echocardiography

Step 4: Timing of CABG

• Delay CABG until:

  • Resolution of acute inflammatory phase (typically 1-2 weeks of treatment)
  • Stabilization of pericardial effusion
  • Normalization of inflammatory markers

• Special perioperative considerations:

  • Careful monitoring for recurrence of pericardial effusion
  • Potential need for continued anti-inflammatory therapy
  • Cautious anticoagulation management

Important Caveats and Pitfalls

1. Pericardial effusion risk: Patients with Dressler syndrome may develop significant pericardial effusion that could progress to cardiac tamponade, which would be a surgical emergency requiring drainage before CABG 3.

2. Medication management: If the patient is on anti-inflammatory medications for Dressler syndrome, consider:

   • Continuing low-dose colchicine through the perioperative period if possible
   • Timing the discontinuation of NSAIDs appropriately (5-7 days before surgery)
   • Managing steroid dosing carefully if the patient is on corticosteroids

3. Anticoagulation considerations: If anticoagulation is needed, balance the risk of bleeding with the risk of thrombosis, particularly if the patient has had recent coronary stenting 6.

4. Decreased incidence: While historically significant, Dressler syndrome has become less common in the modern era of coronary revascularization 7, but remains clinically important when present.

5. Recurrence risk: Be aware that cardiac surgery itself could potentially trigger a recurrence of pericardial inflammation in patients with a history of Dressler syndrome.

By following this algorithm, the surgical team can appropriately time CABG to minimize risks associated with Dressler syndrome while still providing necessary coronary revascularization for patients who meet the indications for surgical intervention.