What is the recommended management and treatment regimen for Dressler syndrome?

Dressler Syndrome: Management and Treatment

First-Line Treatment Recommendation

Treat Dressler syndrome with aspirin 500-1000 mg every 6-8 hours (total 1.5-4 g/day) plus colchicine 0.5-0.6 mg twice daily (if ≥70 kg) or once daily (if <70 kg) for at least 3 months. 1, 2

---

Clinical Recognition

Dressler syndrome presents 1-2 weeks to several months after myocardial infarction with the following features:

• Sharp, pleuritic chest pain that worsens with inspiration and improves when sitting forward—this postural and respiratory relationship distinguishes it from recurrent ischemia 2
• Fever without alternative explanation is a cardinal feature 2
• Pericardial friction rub may be audible but can be absent 2
• Diagnosis requires pleuritic chest pain occurring 2 weeks to 3 months post-MI plus at least one of: pericardial friction rub, PR-segment depression or diffuse ST-elevation, or new/enlarging pericardial effusion 2

The incidence is now rare (<1% of MI patients) in the primary PCI era, typically occurring only after delayed or failed reperfusion 1, 2

---

Treatment Algorithm

Step 1: Initiate Aspirin Plus Colchicine

Aspirin is the preferred NSAID because it improves coronary flow and provides antiplatelet effects at therapeutic doses 2:

• Dose: 500-1000 mg every 6-8 hours (total 1.5-4 g/day) 1, 2

Colchicine dosing based on body weight 1, 2:

• ≥70 kg: 0.5-0.6 mg twice daily
• <70 kg: 0.5-0.6 mg once daily
• Duration: Minimum 3 months, up to 6 months for refractory cases 1, 2
• Colchicine reduces recurrence rates by approximately 50% 1

Step 2: Dose Adjustment Considerations

Adjust colchicine dose in stage 4-5 renal disease, severe hepatic impairment, or when co-administered with P-glycoprotein/CYP3A4 inhibitors to avoid toxicity 2

Step 3: Medication Tapering

When symptoms resolve and inflammatory markers normalize:

• Decrease aspirin gradually by 250-500 mg every 1-2 weeks 1
• Taper one drug at a time before discontinuing colchicine over several months in difficult cases 1

---

Critical Pitfalls and Contraindications

What NOT to Use

Avoid glucocorticoids and NSAIDs other than aspirin (except ibuprofen) as first-line therapy due to increased risks of:

• Recurrent myocardial infarction 2
• Impaired myocardial healing 2
• Potential ventricular rupture 2
• The 2013 ACC/AHA STEMI guidelines classify glucocorticoids and NSAIDs as Class III: Harm for post-MI pericarditis 3

Corticosteroids should be reserved only for refractory cases and used with extreme caution as they may delay myocardial infarction healing 1, 2

Diagnostic Pitfalls

Do not misinterpret pericarditic chest pain for recurrent MI or unstable angina—focus on sharp quality, postural change, and respiratory variation 2

Pericardial effusions >10 mm require urgent investigation for possible subacute ventricular rupture, as two-thirds may progress to tamponade or free-wall rupture 2, 4

---

Mandatory Diagnostic Workup

• Transthoracic echocardiography is mandatory to detect pericardial effusion and evaluate for tamponade 2
• Elevated C-reactive protein confirms ongoing inflammation and is essential for diagnosis 2
• Thoracic ultrasound or chest radiography to assess for pleural effusion 2
• The pericardial effusion is characteristically serosanguinous to hemorrhagic in appearance 4

---

Management of Refractory Cases

For patients who fail first-line therapy:

• Long-term oral corticosteroids (3-6 months) may be considered 1
• Intrapericardial triamcinolone (300 mg/m²) via pericardiocentesis is an alternative 1
• Serial CRP measurements can guide treatment duration and assess therapeutic response 2

---

Special Considerations in the Post-PCI Era

In patients who have undergone recent coronary stenting, there is legitimate concern about high-dose aspirin increasing bleeding risk while on dual antiplatelet therapy 5:

• The combination of colchicine plus acetaminophen has been reported as a successful alternative in case reports 5
• However, guidelines still prioritize aspirin plus colchicine as first-line therapy based on the strongest evidence 1, 2
• If high-dose aspirin is contraindicated, ibuprofen is the only acceptable NSAID alternative as it also enhances coronary flow 2

---

Hospitalization and Monitoring

Hospital admission is mandatory to:

• Monitor for cardiac tamponade 2
• Adjust treatment as needed 2
• Investigate effusions >10 mm for subacute rupture 2

Anticoagulation should be discontinued in the presence of significant (≥1 cm) or enlarging pericardial effusion 3

---

Prognosis

• In-hospital and 1-year mortality rates are comparable between patients with and without post-MI pericarditis 2
• Although early pericarditis signals larger infarct size, it does not independently affect prognosis 2
• Rare but serious complications include hemopericardium, cardiac tamponade (<2% of cases), and constrictive pericarditis (approximately 3% of cases) 2
• The condition typically follows a favorable prognosis despite potential for relapsing course 6