History

Fact Explanation
Pleuritic chest pain This is characteristic. Patients complain of retrosternal or left precordial pain. Characteristically chest pain is relieved by leaning forwards and exacerbated by lying supine. [1,2,3]
Fever [1] Low grade fever is commonly seen. This is due to inflammation of the pericardium. [2]
History of myocardial infarction Dressler’s syndrome is a relatively rare complication of myocardial infarction which occurs within 2 to 10 weeks after a myocardial infarction. [1,2]
Cardiovascular risk factors Obesity, hyperlipidemia, hypertension, smoking, positive family history of ischemic heart diseases are cardiovascular risk factors. [2]
References
  1. HENDRY C, LIEW CK, CHAUHAN A, ZACHARIAS J. A life-saving case of Dressler's syndrome Eur Heart J Acute Cardiovasc Care [online] 2012 Sep, 1(3):232-235 [viewed 20 June 2014] Available from: doi:10.1177/2048872612452319
  2. STEADMAN CD, KHOO J, KOVAC J, MCCANN GP. Dressler's syndrome demonstrated by late gadolinium enhancement cardiovascular magnetic resonance J Cardiovasc Magn Reson [online] , 11(1):23 [viewed 20 June 2014] Available from: doi:10.1186/1532-429X-11-23
  3. TINGLE LE, MOLINA D, CALVERT CW. Acute pericarditis. Am Fam Physician [online] 2007 Nov 15, 76(10):1509-14 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18052017

Examination

Fact Explanation
Fever Low grade fever can be detected in some patients. [1]
Pericardial rub Pericardial rub is heard due to the pericardial inflammation and effusion. It is best heard over the left lower sternal edge in end expiration and the patient should be leaning forward. It occurs as the two pericardial layers rub against each other. [1,2,3]
Ewart's sign This sign is the presence of dullness to percussion in the scapular region. When the fluid filled pericardium bulges and compresses the left lung it collapses resulting dull percussion note. [4]
Pulse Tachycardia is common. Pulsus paradoxus can occur in acute severe effusions. [4]
Respiratory rate Tachypnea can be seen in acute pericarditis. [4]
References
  1. STEADMAN CD, KHOO J, KOVAC J, MCCANN GP. Dressler's syndrome demonstrated by late gadolinium enhancement cardiovascular magnetic resonance J Cardiovasc Magn Reson [online] , 11(1):23 [viewed 20 June 2014] Available from: doi:10.1186/1532-429X-11-23
  2. HENDRY C, LIEW CK, CHAUHAN A, ZACHARIAS J. A life-saving case of Dressler's syndrome Eur Heart J Acute Cardiovasc Care [online] 2012 Sep, 1(3):232-235 [viewed 20 June 2014] Available from: doi:10.1177/2048872612452319
  3. TINGLE LE, MOLINA D, CALVERT CW. Acute pericarditis. Am Fam Physician [online] 2007 Nov 15, 76(10):1509-14 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18052017
  4. GOYLE KK, WALLING AD. Diagnosing pericarditis. Am Fam Physician [online] 2002 Nov 1, 66(9):1695-702 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12449268

Differential Diagnoses

Fact Explanation
Acute coronary syndrome [1] Chest pain is common in both conditions. Patients complain of constricting type left sided chest pain, which radiates to the left arm and jaw. [5] Patients with reinfarction also present with ischemic type chest pain.
Pulmonary embolism [1] Shortness of breath is the commonest presenting complaint. Patients also complain of chest discomfort, anxiety, lightheadedness or blacking out. [6]
Hemopericardium Hemopericardium is a complication of full thickness myocardial infarction and myocardial rupture. [2]
Other causes of pericardial effusion [2] Pericardial effusion can occur secondary to infections, autoimmune diseases, malignancies and tuberculosis. [2]
Myocarditis Myocarditis is the inflammation of the myocardium. Cardiac MRI scan is valuable in diagnosing. Bacteria, viruses, spirochetes and mycotic agents can cause infective myocarditis. Systemic diseases like connective tissue disorders, Kawasaki disease, sarcoidosis and celiac disease can also cause myocarditis. [3]
Constrictive pericarditis This is inflammation and fibrosis of the pericardium. Idiopathic constrictive pericarditis is common nowadays. Tuberculosis is a causative factor in developing countries. [4]
References
  1. STEADMAN CD, KHOO J, KOVAC J, MCCANN GP. Dressler's syndrome demonstrated by late gadolinium enhancement cardiovascular magnetic resonance J Cardiovasc Magn Reson [online] , 11(1):23 [viewed 20 June 2014] Available from: doi:10.1186/1532-429X-11-23
  2. NGUYEN T, KUMAR K, FRANCIS A, WALKER JR, RAABE M, ZIEROTH S, JASSAL DS. Pseudo cardiac tamponade in the setting of excess pericardial fat Cardiovasc Ultrasound [online] :3 [viewed 20 June 2014] Available from: doi:10.1186/1476-7120-7-3
  3. SCHULTZ JC, HILLIARD AA, COOPER LT JR, RIHAL CS. Diagnosis and Treatment of Viral Myocarditis Mayo Clin Proc [online] 2009 Nov, 84(11):1001-1009 [viewed 20 June 2014] Available from: doi:10.1016/S0025-6196(11)60670-8
  4. OSTERBERG L, VAGELOS R, ATWOOD JE. Case presentation and review: constrictive pericarditis. West J Med [online] 1998 Oct, 169(4):232-239 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305302
  5. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 20 June 2014]. Available from: doi: 10.1093/eurheartj/ehm355
  6. GOLDHABER S. Z.. Pulmonary Embolism and Deep Vein Thrombosis. [online] 2002 September, 106(12):1436-1438 [viewed 20 June 2014] Available from: doi:10.1161/01.CIR.0000031167.64088.F6

Investigations - for Diagnosis

Fact Explanation
Full blood count Leukocytosis and left shift is common. [5]
Chest X-ray Although not specific chest X-ray can also detect pericardial effusions of more than 250ml. The cardiac silhouette is enlarged in these instances. [6,8]
Transthoracic echocardiogram Echocardiogram visualizes the pericardial effusion between the visceral and parietal pericardial sacs. This can also demonstrate the hemodynamics in cardiac tamponade. [2,3]
ECG [1] Shows pathological Q waves indicating a previous myocardial infarction. [5] Gradual repolarization changes are indicative of pericarditis. During the early stages upwardly concave ST-segment elevation can be seen in all the leads. T-wave inversion and PR-segment depression can be seen in ECG. [7]
Cardiac MRI scan (CMR) or CT scan These are valuable investigation modalities to diagnose pericardial pathologies. In Dressler's syndrome global pericardial inflammation can be detected. [1,2]
Late gadolinium enhancement scan [2] Shows pericardial inflammation and thickening. This test has high sensitivity and specificity in detecting pericardial inflammation. [2]
C-reactive protein (CRP) CRP is elevated as a result of pericardial inflammation. [2]
Erythrocyte sedimentation rate (ESR) [4] ESR is raised in some patients due to pericardial inflammation.
Antimyocardial antibodies Positive antimyocardial antibodies suggest the diagnosis. [4]
References
  1. HENDRY C, LIEW CK, CHAUHAN A, ZACHARIAS J. A life-saving case of Dressler's syndrome Eur Heart J Acute Cardiovasc Care [online] 2012 Sep, 1(3):232-235 [viewed 20 June 2014] Available from: doi:10.1177/2048872612452319
  2. STEADMAN CD, KHOO J, KOVAC J, MCCANN GP. Dressler's syndrome demonstrated by late gadolinium enhancement cardiovascular magnetic resonance J Cardiovasc Magn Reson [online] , 11(1):23 [viewed 20 June 2014] Available from: doi:10.1186/1532-429X-11-23
  3. NGUYEN T, KUMAR K, FRANCIS A, WALKER JR, RAABE M, ZIEROTH S, JASSAL DS. Pseudo cardiac tamponade in the setting of excess pericardial fat Cardiovasc Ultrasound [online] :3 [viewed 20 June 2014] Available from: doi:10.1186/1476-7120-7-3
  4. WILLIAMS RK, NAGLE RE, THOMPSON RA. Postcoronary pain and the postmyocardial infarction syndrome. Br Heart J [online] 1984 Mar, 51(3):327-329 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC481507
  5. BOUSHAHRI ALI. Post-myocardial infarction (Dressler’s) syndrome following early reperfusion. Br J Cardiol [online] 2012 December [viewed 20 June 2014] Available from: doi:10.5837/bjc.2012.019
  6. WEISER N. J., KANTOR M., RUSSELL H. K.. Postmyocardial Infarction Syndrome. Circulation [online] 1959 September, 20(3):371-380 [viewed 20 June 2014] Available from: doi:10.1161/01.CIR.20.3.371
  7. TINGLE LE, MOLINA D, CALVERT CW. Acute pericarditis. Am Fam Physician [online] 2007 Nov 15, 76(10):1509-14 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18052017
  8. GOYLE KK, WALLING AD. Diagnosing pericarditis. Am Fam Physician [online] 2002 Nov 1, 66(9):1695-702 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12449268

Investigations - Followup

Fact Explanation
Transthoracic echocardiogram Constrictive pericarditis is a rare but significant complication of recurrent pericardial effusions. [1]
References
  1. CHEUNG PK, MYERS ML, ARNOLD JM. Early constrictive pericarditis and anemia after Dressler's syndrome and inferior wall myocardial infarction. Br Heart J [online] 1991 Jun, 65(6):360-362 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1024684

Management - Specific Treatments

Fact Explanation
Non-steroidal anti-inflammatory drugs Although many patients recover even without treatment, non-steroidal anti-inflammatory drugs are used in treatment. Ibuprofen is preferred because it suppresses the pericardial inflammation and simultaneously improves the coronary perfusion. [1,2,3]
Corticosteroids Steroids also suppress the inflammation, but it should be used with caution as it prolongs the cardiac remodeling as well. [3]
Pericardiocenthesis This is useful if the pericardial effusion is large and if it causes significant tamponade effects. [3]
Intrapericardial fibrin-glue instillation Helpful in subacute cardiac tamponade. [3]
References
  1. CHEUNG PK, MYERS ML, ARNOLD JM. Early constrictive pericarditis and anemia after Dressler's syndrome and inferior wall myocardial infarction. Br Heart J [online] 1991 Jun, 65(6):360-362 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1024684
  2. STREIFLER J, PITLIK S, DUX S, PERRY G, HELLMAN C, GREENWALD M, ROSENFELD JB. Dressler's syndrome after right ventricular infarction. Postgrad Med J [online] 1984 Apr, 60(702):298-300 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2417818
  3. Guidelines on the Diagnosis and Management of Pericardial Diseases Executive SummaryThe Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. European Heart Journal [online] 2004 April, 25(7):587-610 [viewed 20 June 2014] Available from: doi:10.1016/j.ehj.2004.02.002