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Post-myocardial infarction syndrome: Explanation of what and why this syndrome occurs

Heart | November 24, 2014 | Author: The Super Pharmacist

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Post-myocardial infarction syndrome: Explanation of what and why this syndrome occurs

Post-myocardial infarction syndrome was first described by a physician named Dressler in the spring of 1956. In fact, post-myocardial infarction syndrome is also known as Dressler syndrome. Post-myocardial infarction syndrome is a collection of signs and symptoms that occurs within days to weeks after a myocardial infarction (heart attack). This syndrome includes a protracted fever, chest pain, elevated white blood cell count, and inflammation of various structures within the chest including pericarditis, pleurisy, and pneumonitis. There may also be pericardial effusion and plural effusion, which is an abnormal collection of fluid around the heart or around the lungs, respectively. The syndrome may occur once and then no more or it may relapse several times over the course of months for up to two years after the first episode.

What causes post-myocardial infarction syndrome?

The symptoms of Dressler syndrome are those of acute inflammation, so immunologic factors are believed to be the key drivers of the syndrome. Researchers believe that damage to the heart tissue releases certain antigens into the bloodstream that the immune system then recognises as abnormal and mounts and inflammatory attack. These immune complexes develop in the sac around the heart (the pericardium), the lining of the lungs (the pleura), and in the lungs themselves. Interestingly, the symptoms of post-myocardial infarction syndrome do not only occur after a heart attack, indeed any situation in which the heart is acutely injured can cause this inflammatory syndrome. For instance, any open-heart surgery in which the pericardial sac is opened may cause this exact syndrome. Therefore, Dressler syndrome/post-myocardial infarction syndrome has been renamed as post-cardiac injury syndrome to account for this variety of possible causes.

Incidence, risk factors and prevention

What causes post-myocardial infarction syndrome?Dressler and several colleagues noted that post-myocardial infarction syndrome occurred in 44 patients under their care. Thus, he estimated that between 3 and 4% of all people who experience heart attack would develop this syndrome.

Estimates on a larger group of patients showed that this syndrome was much less common, occurring after less than 1% of heart attacks. In fact, the incidence of post-myocardial infarction syndrome may be even lower now that thrombolytics and reperfusion procedures such as angioplasty and stenting have become the norm. With the advent of effective treatments for heart attack, Dressler syndrome is a relatively rare occurrence. Nevertheless, those who do not seek or cannot receive prompt treatment for a heart attack may experience this syndrome. Thus, the main risk factor for post-myocardial infarction syndrome is ineffective treatment of heart attack.

Taken a step further, the standard risk factors for coronary heart disease such as smoking, abnormal blood cholesterol, diabetes, high blood pressure, etc., are indirectly risk factors for Dressler syndrome. The only viable preventative steps are to reduce the risk of heart attack and to seek prompt, expert medical care in the event of a myocardial infarction.

Treatment for post-myocardial infarction syndrome

Dressler syndrome is a self-limited disease, which means that it will go away on its own in time. Nonetheless, the inflammatory syndrome is usually treated with non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen. In severe cases, post-myocardial infarction syndrome is treated with corticosteroids, such as prednisone; however, these powerful anti-inflammatory drugs may interfere with the heart's ability to heal after a heart attack. Therefore, NSAIDs are the drugs of choice for this syndrome. Patients may be given colchicine, a drug that is better known as a treatment for gout but may be helpful for pericarditis. Unfortunately and for reasons that are not clearly understood, some patients with post-myocardial infarction syndrome will have flare-ups periodically for up to two years. In these cases, colchicine may be particularly helpful. Although because of the rarity of the syndrome, the scientific support for the benefit of colchicine is limited.

Living with post-myocardial infarction syndrome

Because the syndrome is so rare, patients with this condition may feel isolated and abnormal. Also because of the rarity of the illness, many physicians may not think of this diagnosis.

Living with post-myocardial infarction syndromeThus, proper diagnosis is important. It is also important to recognise that Dressler syndrome will eventually go away and effective treatments are available. It is important to seek out a physician who is aware of the diagnosis and who can properly manage the condition. Depression, anxiety, and fear are unfortunately common occurrences after myocardial infarction, but they are not normal and should be treated appropriately.

The importance of an accurate diagnosis

Since post-myocardial infarction syndrome is so rare and several other complications can occur after heart attack, is critical that physicians correctly differentiate between this syndrome and other causes of chest pain.

Peri-infarction pericarditis

A condition called peri-infarction pericarditis is similar to Dressler syndrome and is detected on physical examination as a pericardial friction rub, something that can be heard by physician using a stethoscope on the chest. Almost all cases of peri-infarction pericarditis will resolve within three days after heart attack. Therefore, treatment is usually not given. In persistent cases, patients are given aspirin and colchicine.

Pericardial effusion

A pericardial effusion is common after a heart attack and may occur in up to as many as one third of all patients with myocardial infarction. As long as cardiac tamponade (fluid compressing the heart) does not occur, and it rarely does, a pericardial effusion that occurs after heart attack will go away on its own. A very small number of these effusions will last longer than one year. No specific therapy is warranted.

Congestive heart failure

Congestive heart failure is a much more likely occurrence after a heart attack than post-myocardial infarction syndrome. Damaged heart muscle is no longer able to pump effectively and therefore fluid may accumulate in the lungs, causing a pleural effusion.

It is also possible that individuals with congestive heart failure run a small fever (incidentally, the fever of post-myocardial infarction syndrome can be quite high; as high as 104°F).

There are numerous, specific treatments for congestive heart failure that should be given. On the other hand, if a person has post-myocardial infarction syndrome that is mimicking congestive heart failure, these treatments should be withheld.

Recurrent heart attack

A myocardial infarction that was not effectively or definitively treated, such as with a stent, may recur. The recurrent heart attack may cause chest pain, elevated body temperature, and shortness of breath. It is vital that diagnosing physicians not miss the diagnosis of a second myocardial infarction, which could be life threatening.

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References

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Galve E, Garcia-Del-Castillo H, Evangelista A, Batlle J, Permanyer-Miralda G, Soler-Soler J. Pericardial effusion in the course of myocardial infarction: incidence, natural history, and clinical relevance. Circulation. Feb 1986;73(2):294-299.

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