History

Fact Explanation
A predisposing conditon Postcardiotomy/pericardiotomy syndrome is a condition which, in some patients, follows a traumatic incident which results in opening of the pericardium. It is an uncommon complication of cardiac surgeries, myocardial infarction, blunt or penetrating chest trauma or procedures involving pericardiotomy. [1] [2] [3] [4] [5] [6] [7] [8] [9] The underlying pathology is development of an immune reaction the cardiac or pericardial tissue due to development of anti-heart antibodies. Presence of microbiological agents also have been studied. [10] [11] [12] The average time for onset of symptoms following a predisposing condition is around 20 days. [13]
Fever Due to the inflammatory reaction. [2] [5] [9] [13]
Chest pain Chest pain with relation to the inspiration phase of respiration is an important indicative factor of pericardial effusion. The pain can be exertional, radiated to abdomen, shoulders or back of the chest. [5] [6] [7] [9] [13]
Difficulty in breathing Due to pleural effusion, it was present in more than half of the patients in one study. [13]
Arthalrgia Due to autoimmune arthopathy. [14]
References
  1. RHEE C, SAX PE. Evaluation of Fever and Infections in Cardiac Surgery Patients. Semin Cardiothorac Vasc Anesth [online] 2014 Jun 22 [viewed 10 August 2014] Available from: doi:10.1177/1089253214538524
  2. LOGAN A, TURNER R. Post-cardiotomy Syndrome Br Med J [online] 1963 Oct 26, 2(5364):1068 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1873177
  3. GUNGOR BARIS, UCER EKREM, ERDINLER İZZET CELAL. Uncommon presentation of postcardiac injury syndrome: Acute pericarditis after percutaneous coronary intervention. International Journal of Cardiology [online] 2008 August, 128(1):e19-e21 [viewed 10 August 2014] Available from: doi:10.1016/j.ijcard.2007.04.159
  4. LOGAN A. POSTCARDIOTOMY SYNDROME. The Lancet [online] 1961 April [viewed 10 August 2014] Available from: doi:10.1016/S0140-6736(61)90157-X
  5. BOUSHAHRI ALI. Post-myocardial infarction (Dressler’s) syndrome following early reperfusion. Br J Cardiol [online] 2012 December [viewed 10 August 2014] Available from: doi:10.5837/bjc.2012.019
  6. DRESSLER WILLIAM. The Post-Myocardial-Infarction Syndrome. AMA Arch Intern Med [online] 1959 January [viewed 10 August 2014] Available from: doi:10.1001/archinte.1959.00270010034006
  7. DRESSLER WILLIAM. A POST-MYOCARDIAL-INFARCTION SYNDROME. JAMA [online] 1956 April [viewed 10 August 2014] Available from: doi:10.1001/jama.1956.02960510005002
  8. CEVIK CIHAN, WILBORN TROY, CORONA RITA, SCHANZMEYER ELIZABETH, NUGENT KENNETH. Post-cardiac injury syndrome following transvenous pacemaker insertion: A case report and review of the literature. Heart, Lung and Circulation [online] 2009 December, 18(6):379-383 [viewed 10 August 2014] Available from: doi:10.1016/j.hlc.2009.04.00
  9. HARRIS DAVID G, JANSON JACQUES T, VAN WYK JACQUES, PRETORIUS JOHANN, ROSSOUW GAWIE J. Delayed pericardial effusion following stab wounds to the chest. European Journal of Cardio-Thoracic Surgery [online] 2003 April, 23(4):473-476 [viewed 10 August 2014] Available from: doi:10.1016/S1010-7940(03)00006-X
  10. ROBINSON J, BRIGDEN W. Immunological Studies in the Post-cardiatomy Syndrome Br Med J [online] 1963 Sep 21, 2(5359):706-709 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1872879
  11. ENGLE MA, ZABRISKIE JB, SENTERFIT LB. Heart-reactive antibody, viral illness, and the postpericardiotomy syndrome. Correlates of a triple-blind, prospective study. Trans Am Clin Climatol Assoc [online] 1976:147-160 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2441394
  12. DRUSIN LEWIS M., ENGLE MARY ALLEN, HAGSTROM JACK W. C., SCHWARTZ MELVIN S.. The Postpericardiotomy Syndrome. N Engl J Med [online] 1965 March, 272(12):597-602 [viewed 10 August 2014] Available from: doi:10.1056/NEJM196503252721201
  13. STELZNER T J. The pleuropulmonary manifestations of the postcardiac injury syndrome.. CHEST [online] 1983 October [viewed 10 August 2014] Available from: doi:10.1378/chest.84.4.383
  14. DAVIDSON C. Arthropathy in Dressler's syndrome. Postgrad Med J [online] 1981 Jan, 57(663):60-61 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424786

Examination

Fact Explanation
Fever Due to the inflammatory reaction. [1] [2] [3]
Pericardial friction rub Due to autoimmune inflammation of the pericardium. [4]
Ascites Systemic fluid collections are also common findings. [5]
References
  1. LOGAN A, TURNER R. Post-cardiotomy Syndrome Br Med J [online] 1963 Oct 26, 2(5364):1068 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1873177
  2. BOUSHAHRI ALI. Post-myocardial infarction (Dressler’s) syndrome following early reperfusion. Br J Cardiol [online] 2012 December [viewed 10 August 2014] Available from: doi:10.5837/bjc.2012.019
  3. HARRIS DAVID G, JANSON JACQUES T, VAN WYK JACQUES, PRETORIUS JOHANN, ROSSOUW GAWIE J. Delayed pericardial effusion following stab wounds to the chest. European Journal of Cardio-Thoracic Surgery [online] 2003 April, 23(4):473-476 [viewed 10 August 2014] Available from: doi:10.1016/S1010-7940(03)00006-X
  4. STELZNER T J. The pleuropulmonary manifestations of the postcardiac injury syndrome.. CHEST [online] 1983 October [viewed 10 August 2014] Available from: doi:10.1378/chest.84.4.383
  5. HARRIS DAVID G, JANSON JACQUES T, VAN WYK JACQUES, PRETORIUS JOHANN, ROSSOUW GAWIE J. Delayed pericardial effusion following stab wounds to the chest. European Journal of Cardio-Thoracic Surgery [online] 2003 April, 23(4):473-476 [viewed 10 August 2014] Available from: doi:10.1016/S1010-7940(03)00006-X

Differential Diagnoses

Fact Explanation
Endocarditis Since the presentation is following a traumatic event to the heart, when a patient presents with fever and chest pain, one's first differential should be infective endocarditis. The usual sequence of investigations for diagnosis should be done in where it is suspected. [1] [2]
Congestive cardiac failure Congestive cardiac failure can also mimic postcardiotomy syndrome following an acute myocardial infarction, the subtle clinical signs should be evaluated therefore. Echocardiogram can differentiate the two entities. [3] [4] [5] [6] [7]
References
  1. BADDOUR L. M.. Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: Endorsed by the Infectious Diseases Society of America. Circulation [online] 2005 June, 111(23):e394-e434 [viewed 10 August 2014] Available from: doi:10.1161/​CIRCULATIONAHA.105.165564
  2. MCDONALD JAY R.. Acute Infective Endocarditis. Infectious Disease Clinics of North America [online] 2009 September, 23(3):643-664 [viewed 10 August 2014] Available from: doi:10.1016/j.idc.2009.04.013
  3. YANCY C. W., JESSUP M., BOZKURT B., BUTLER J., CASEY D. E., DRAZNER M. H., FONAROW G. C., GERACI S. A., HORWICH T., JANUZZI J. L., JOHNSON M. R., KASPER E. K., LEVY W. C., MASOUDI F. A., MCBRIDE P. E., MCMURRAY J. J. V., MITCHELL J. E., PETERSON P. N., RIEGEL B., SAM F., STEVENSON L. W., TANG W. H. W., TSAI E. J., WILKOFF B. L.. 2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 128(16):1810-1852 [viewed 10 August 2014] Available from: doi:10.1161/​CIR.0b013e31829e8807
  4. SIU C, YEUNG C, LAU C, KUNG AW, TSE H. Incidence, clinical characteristics and outcome of congestive heart failure as the initial presentation in patients with primary hyperthyroidism Heart [online] 2007 Apr, 93(4):483-487 [viewed 10 August 2014] Available from: doi:10.1136/hrt.2006.100628
  5. American Heart Association. Classes of heart failure. [web] [viewed 10 August 2014] Available from: http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp
  6. COATS AJ. Heart Failure: Pathogenesis and Treatment J R Soc Med [online] 2002 Oct, 95(10):523-524 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279191
  7. HARRIS DAVID G, JANSON JACQUES T, VAN WYK JACQUES, PRETORIUS JOHANN, ROSSOUW GAWIE J. Delayed pericardial effusion following stab wounds to the chest. European Journal of Cardio-Thoracic Surgery [online] 2003 April, 23(4):473-476 [viewed 10 August 2014] Available from: doi:10.1016/S1010-7940(03)00006-X

Investigations - for Diagnosis

Fact Explanation
Complete blood count Leucocytosis is the expected finding. [1] [2] [3]
Erythrocyte sedimentation rate Increased due to inflammatory reaction. [1] [2] [4] [5] [6]
Anti-heart antibodies Auto-antibodies are positive since it is an autoimmune condition. [7] [8] [9]
Chest X-ray To look for evidence of pericardial and/ or pleural effusion. [3] [10]
Echocardiography It is the diagnostic test. [1] [11]
12 lead electrocardiogram Might mimic pericarditis initially. [3] [12] [13]
References
  1. STELZNER T J. The pleuropulmonary manifestations of the postcardiac injury syndrome.. CHEST [online] 1983 October [viewed 10 August 2014] Available from: doi:10.1378/chest.84.4.383
  2. KHAN ABDUL HAKIM. The postcardiac injury syndromes. Clin Cardiol [online] 1992 February, 15(2):67-72 [viewed 10 August 2014] Available from: doi:10.1002/clc.4960150203
  3. WEERAKKODY Y et al. Dressler's syndrome. [web] [viewed 10 August 2014] Available from: http://radiopaedia.org/articles/dresslers-syndrome
  4. BAJAJ BPS et al. Postpericardiotomy syndrome following temporary and permanent transvenous pacing. Postgrad Med J [online] 1999;75:357-359 [viewed 10 August 2014] Available from: http://pmj.bmj.com/content/75/884/357.full
  5. WALTON K, HOLT PJ. Rheumatic symptoms after cardiac surgery: a prospective study. BMJ [online] 1988 Jul 2, 297(6640):21-24 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1834157
  6. PARK JIN-SEOK, KIM DAE-HYEOK, CHOI WOONG-GIL, WOO SEOUNG-IL, KWAN JUN, PARK KEUM-SOO, LEE WOO-HYUNG, LEE JUNG-JIN, CHOI YONG-JUN. Postcardiac Injury Syndrome after Percutaneous Coronary Intervention. Yonsei Med J [online] 2010 December [viewed 10 August 2014] Available from: doi:10.3349/ymj.2010.51.2.284
  7. ENGLE MA, ZABRISKIE JB, SENTERFIT LB. Heart-reactive antibody, viral illness, and the postpericardiotomy syndrome. Correlates of a triple-blind, prospective study. Trans Am Clin Climatol Assoc [online] 1976:147-160 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2441394
  8. ENGLE MA, ZABRISKIE JB, SENTERFIT LB. Heart-reactive antibody, viral illness, and the postpericardiotomy syndrome. Correlates of a triple-blind, prospective study. Trans Am Clin Climatol Assoc [online] 1976:147-160 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2441394
  9. ROBINSON J, BRIGDEN W. Immunological Studies in the Post-cardiatomy Syndrome Br Med J [online] 1963 Sep 21, 2(5359):706-709 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1872879
  10. MECHEM C.CRAWFORD, ALAM GEORGE A.. Delayed cardiac tamponade in a patient with penetrating chest trauma. The Journal of Emergency Medicine [online] 1997 January, 15(1):31-33 [viewed 10 August 2014] Available from: doi:10.1016/S0736-4679(96)00240-5
  11. HARRIS DAVID G, JANSON JACQUES T, VAN WYK JACQUES, PRETORIUS JOHANN, ROSSOUW GAWIE J. Delayed pericardial effusion following stab wounds to the chest. European Journal of Cardio-Thoracic Surgery [online] 2003 April, 23(4):473-476 [viewed 10 August 2014] Available from: doi:10.1016/S1010-7940(03)00006-X
  12. NIJJER S. S., DUBREY S. W., DREYFUS G. D., GROCOTT-MASON R.. Delayed pericardial effusions: life-threatening complication presenting up to 100 days after chest trauma. Clinical Medicine [online] 2010 February, 10(1):88-90 [viewed 10 August 2014] Available from: doi:10.7861/clinmedicine.10-1-88
  13. CEVIK CIHAN, WILBORN TROY, CORONA RITA, SCHANZMEYER ELIZABETH, NUGENT KENNETH. Post-cardiac injury syndrome following transvenous pacemaker insertion: A case report and review of the literature. Heart, Lung and Circulation [online] 2009 December, 18(6):379-383 [viewed 10 August 2014] Available from: doi:10.1016/j.hlc.2009.04.00

Management - General Measures

Fact Explanation
Patient education Education of the patient regarding the diagnosis, and the good prognosis of the condition even though there can be progressive nature and recurrences. [1] [2]
References
  1. FLETCHER C., OSTERGAARD C., MENZIES R.. Dressler Syndrome after Minimally Invasive Coronary Artery Bypass Surgery. The Journal of the American Board of Family Medicine [online] 2004 May, 17(3):230-232 [viewed 10 August 2014] Available from: doi:10.3122/jabfm.17.3.230
  2. SHABETAI R.. Corticosteroids for Recurrent Pericarditis: On the Road to Evidence-Based Medicine. Circulation [online] 2008 August, 118(6):612-613 [viewed 10 August 2014] Available from: doi:10.1161/​CIRCULATIONAHA.108.795567

Management - Specific Treatments

Fact Explanation
Non-steroidal anti-inflammatory drugs Oral non steroidal anti inflammatory drugs usually receive a good response in milder cases. i.e. Aspirin. The dose can be reduced with the response. [1] [2] [3]
Corticosteroids Given for a short course of high dose and then tapered off.
Intravenous immunoglobulin Given in single high dose has the best outcome. [8]
Pericardiocentesis In severe cases of pericardial effusions. Sometimes it can be life-saving. The pericardial fluid should be sent for analysis including microbiological studies. [9] [10]
References
  1. CEVIK CIHAN, WILBORN TROY, CORONA RITA, SCHANZMEYER ELIZABETH, NUGENT KENNETH. Post-cardiac injury syndrome following transvenous pacemaker insertion: A case report and review of the literature. Heart, Lung and Circulation [online] 2009 December, 18(6):379-383 [viewed 10 August 2014] Available from: doi:10.1016/j.hlc.2009.04.001
  2. IMAZIO MASSIMO, HOIT BRIAN D.. Post-cardiac injury syndromes. An emerging cause of pericardial diseases. International Journal of Cardiology [online] 2013 September, 168(2):648-652 [viewed 10 August 2014] Available from: doi:10.1016/j.ijcard.2012.09.052
  3. SHABETAI R.. Corticosteroids for Recurrent Pericarditis: On the Road to Evidence-Based Medicine. Circulation [online] 2008 August, 118(6):612-613 [viewed 10 August 2014] Available from: doi:10.1161/​CIRCULATIONAHA.108.795567
  4. FINK D., FRIGIOLA A., CULLEN S.. Postcardiotomy syndrome: recurrent cardiac tamponade and an exquisite steroid response. Case Reports [online] December, 2012(dec19 1):bcr2012007761-bcr2012007761 [viewed 10 August 2014] Available from: doi:10.1136/bcr-2012-007761
  5. FLOERCHINGER BERNHARD, CAMBONI DANIELE, SCHOPKA SIMON, KOLAT PHILIPP, HILKER MICHAEL, SCHMID CHRISTOF. Delayed cardiac tamponade after open heart surgery - is supplemental CT imaging reasonable?. Array [online] 2013 December [viewed 10 August 2014] Available from: doi:10.1186/1749-8090-8-158
  6. KHAN ABDUL HAKIM. The postcardiac injury syndromes. Clin Cardiol [online] 1992 February, 15(2):67-72 [viewed 10 August 2014] Available from: doi:10.1002/clc.4960150203
  7. DAVIDSON C. Arthropathy in Dressler's syndrome. Postgrad Med J [online] 1981 Jan, 57(663):60-61 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424786
  8. WENDELIN G., FANDL A., BEITZKE A.. High-Dose Intravenous Immunoglobulin in Recurrent Postpericardiotomy Syndrome. Pediatr Cardiol [online] December, 29(2):463-464 [viewed 10 August 2014] Available from: doi:10.1007/s00246-007-9025-y
  9. HARRIS DAVID G, JANSON JACQUES T, VAN WYK JACQUES, PRETORIUS JOHANN, ROSSOUW GAWIE J. Delayed pericardial effusion following stab wounds to the chest. European Journal of Cardio-Thoracic Surgery [online] 2003 April, 23(4):473-476 [viewed 10 August 2014] Available from: doi:10.1016/S1010-7940(03)00006-X
  10. STELZNER T J. The pleuropulmonary manifestations of the postcardiac injury syndrome.. CHEST [online] 1983 October [viewed 10 August 2014] Available from: doi:10.1378/chest.84.4.383