Inferior infarction and Dressler's syndrome

Tracing
N° 55
Library
Patient
83-year-old man with an anterior infarction 10 years earlier, hospitalized 48 hours after the onset of typical chest pain; troponin peak on hospital arrival is high, the following electrocardiogram is recorded;
Inferior infarction and Dressler's syndrome
Inferior infarction and Dressler's syndrome
Comments

This patient presented an inferior infarction examined belatedly and without possible reperfusion followed by a Dressler’s syndrome a few weeks after the patient's discharge with the presence of moderate left pleural effusion, pericardial effusion and hyperleukocytosis. Anti-inflammatory treatment allowed eliminating the symptomatology.

Dressler’s syndrome initially described in 1956 corresponds to a complication occurring in post-infarction. Since the introduction of fibrinolytic therapy and angioplasty in the acute phase, its incidence has considerably decreased. Indeed, a rapid reperfusion allows to limit the extension of the necrosis. Dressler's syndrome is more frequent in instances of extensive infarction and late reperfusion. This complication usually occurs after a few weeks of latency (usually between 2 and 5 weeks) in the aftermath of a major infarction. Dressler’s syndrome is typically manifested by a resurgence of chest pain exacerbated at inspiration associated with: fever, cough, pericardial friction (less common), a biological inflammatory syndrome (hyperleukocytosis, increased SR and CRP), a pleural effusion most often left-sided, and a possible moderate pericardial effusion. The occurrence of tamponade in this setting is rare. The underlying pathophysiological mechanism is not clearly established although an autoimmune mechanism may explain the occurrence of symptomatology after a latency phase.

The electrocardiogram can reveal the usual signs of pericarditis even if the diagnosis can be rendered difficult by the concomitant changes in relation to the post-infarction. A widespread T-wave inversion is probably the most frequent sign.

Evolution is most often spontaneously favorable although with a possible risk of recurrence in the following weeks. Therapeutic management is largely empirical and is based on the introduction of non-steroidal anti-inflammatory drugs or large-dose aspirin. Corticosteroid therapy or colchicine therapy may be considered for resistant or recurrent forms. 

Epigraph
Dressler’s syndrome corresponds to a pericarditis occurring a few weeks after an extensive infarction. Its incidence has considerably decreased since the development of reperfusion techniques. It should nevertheless be evoked in a non-reperfused or late-reperfused patient with typical symptomatology.