The syndrome of Dressler( postinfarction syndrome) - Causes, symptoms and treatment. MF.

Causes of

Symptoms
Diagnosis
Treatment of
Lifestyle, complications and prognosis

Myocardial infarction is dangerous not only because it causes a significant disruption of the cardiovascular system, but also because it can lead to complications. One of them is Dressler's syndrome, or post-infarction syndrome.

Dressler's syndrome is an autoimmune lesion of connective tissue in the body of a patient who underwent an extensive myocardial infarction. It is manifested by fever, lesions of the pericardium, pleura, pulmonary tissue and articular membranes. It develops in 4% of all cases for 10-14 days from the onset of a heart attack. The danger of this syndrome is that it can last for a long time, with periodic exacerbations and remissions, disrupting the patient's quality of life and well-being.

The following forms of the syndrome are distinguished:

1. A typical form is characterized by various combinations of connective tissue damage:
- pericardial variant
- pleural
- pneumonic

- pericardial pneumonic
- pericardial-pleural
- pleuropneumatic
- pericardial-pleural pneumonia
2. Atypical form is manifested by cardio-brachial, arthritic, dermal, peritoneal variants.
3. Malosymptomatic( erased) form is manifested by subfebrile fever, pain in joints and changes in general blood analysis.

Causes of Dressler's syndrome

The main cause of the disease is the damage and death( necrosis) of cardiac muscle cells in acute myocardial infarction, the release of decomposition products into the blood and autosensitization( increased immune sensitivity directed to the body's own tissues) to the denatured protein of dead cells. There is an aggression of immune cells responsible for recognition of antigens( foreign substances), but in this case this reaction is directed against protein molecules located on the cells of the membranes lining the heart, lungs and joints - pericardium, pleura and synovial( articular) membranes. As a result, there is a cross-autoimmune reaction with its own cells, which the body regards as alien. Pleura, pericardium and synovial membranes become inflamed, but the inflammation is aseptic, without bacteria and viruses, and secrete some fluid that accumulates between the pleura and pericardium sheets, as well as in the joints, causing pain and impairment.

Not only a large focal or transmural myocardial infarction can cause Dressler's syndrome, but also surgical interventions on the heart. After reconstructive operations on the mitral valve, postcomussorotomy syndrome rarely develops, and after cardiac interventions with pericardial dissection, postcardiotomy syndrome. These variants are similar to the postinfarction syndrome in terms of causes, mechanisms of development, clinical manifestations and treatment, therefore they are collectively referred to as Dressler's syndrome.

The patient's systemic autoimmune diseases( systemic lupus erythematosus, rheumatoid arthritis, etc.), as well as late motor activation of the patient after a heart attack, increase the risk of this complication.

Symptoms of Dressler's syndrome

Clinical manifestations can occur in the time interval from two weeks to two months after an acute infarction. The Dressler syndrome manifests itself with such signs:

- General malaise and poor health.
- The temperature rise of often occurs before subfebrile digits( no higher than 39 0С), in the interictal period there may be a persistent subfebrile condition( 37.3-38 ° C).
- Pericarditis is an indispensable symptom of Dressler's syndrome. It is manifested by pain in the region of the heart of an acute, pressing, compressive nature, intensifying at the height of inspiration and when coughing and disappearing in the supine or sitting position with a forward inclination. Can give in the neck, shoulder and left arm.
- Pneumonitis ( not to be confused with pneumonia - inflammatory bacterial or viral lung injury) develops due to damage to the interstitial tissue of the lungs and manifests diffuse pain in the chest on both sides, dyspnoea with exercise and dry cough, sometimes with blood veins. When a patient complains of shortness of breath, coughing and hemoptysis, the doctor should think about another formidable complication of the infarct - thromboembolism of the pulmonary artery.
- pleurisy is manifested by superficial pain in the left half of the chest, more laterally and posteriorly and with a dry cough. Pain and cough alone disappear within two to four days. Pleurisy in combination with signs of pericarditis, pneumonitis and temperature makes it possible to reliably assume the diagnosis of Dressler's syndrome.

The figure shows the effusion in the pleural cavity

- The chest-shoulder-arm syndrome ( cardiothoracic syndrome) is currently developing much less frequently than before, which is associated with an earlier activation of the patient after a heart attack. It is manifested by pain in the left shoulder region, impaired sensation in the left arm, numbness and "crawling" in the hand, pale, marbled skin of the hand and hand.
- The anterior thoracic wall syndrome is caused by the progression of joint osteochondrosis at the junction of the sternum and clavicle, and is most likely also associated with prolonged immobility of the patient in the acute period of the infarction. It is manifested by pain and swelling in the sternum and clavicle on the left.
- Skin manifestations of : rashes on the skin that resemble hives, dermatitis, eczema or erythema may develop.

In most cases there is a chronic course of the syndrome with exacerbations, which last from several days to 3-4 weeks, and remissions lasting several months. Rarely there is a single attack with full recovery.

Diagnosis of Dresser's

Diagnosis can be suspected on the basis of the patient's characteristic complaints after a heart attack in the last two months, as well as on the basis of the patient's examination data - a pericardial and pleural friction noise, wet wheezes in the lower lungs are heard during thoracic auscultation. Additional diagnostic methods may be prescribed to clarify the diagnosis:

- An expanded blood test - an increase in the number of leukocytes( more than 10 x 109 / L), an acceleration of ESR( more than 20 mm / h), an increase in the number of eosinophils( more than 5% in the leukocyte formula).
- Biochemical blood test, rheumatological tests, immunological studies. An increased level of C - reactive protein is determined, the level of MB fraction of creatine phosphokinase and troponins( markers of acute infarction) may be increased, but not always, which requires differential diagnosis with repeated myocardial infarction.
- ECG does not reveal any significant deviations, except for the signs of a cicatrial infarction.
- Echocardiography reveals a thickening of pericardial sheets, a restriction of their mobility, the presence of fluid( effusion) in the pericardial cavity. Areas of reduced contractility of the myocardium( hypokinesia), indicating a transferred heart attack, are determined.
- Radiography of the chest - the thickening of the interlobar pleura in pleurisy is determined, there may be diffuse enhancement of the pulmonary pattern, linear or focal darkening in the lung tissue with pneumonitis, an increase in the cardiac shadow with pericarditis.
- Radiography of the shoulder joints can show a narrowing of the joint gap, thickening of the bone tissue and other signs of previous osteoarthritis.
- CT or MRI of the thorax is prescribed in diagnostic vague cases to clarify the nature of pericarditis, pleurisy and pneumonitis.

Treatment of Dressler's syndrome

Therapy of a syndrome that has arisen for the first time in life should be performed in a hospital. Subsequent relapses can be treated outpatient with a mild course.

From preparations intravenously and in tableted forms are appointed:

- prednisolone, dexamethasone and other glucocorticoid hormones in a daily dose of 30 - 40 mg. Improvement of the condition is observed already on the second - the third day from the beginning of treatment with hormones, but therapy should be long, for several weeks and months, as with the cancellation of drugs a new relapse is possible. It is necessary to gradually phase out prednisolone, with a decrease in dosage by 5 mg per week until complete discontinuation of the drug.
- non-steroidal anti-inflammatory drugs( NSAIDs): diclofenac, indomethacin, aspirin, nimesulide, dosages are determined by the attending physician.
- antibiotics are ineffective, but can be prescribed for difficulties in differential diagnosis with infection of the lungs, pericardium and joints.
- cardiotropic drugs for IHD therapy - aspirin, bettablockers, lipid-lowering drugs( statins), ACE inhibitors, etc.
- analgin with dimedrol intramuscularly with severe pain syndrome.

In addition to drug therapy, in cases of pronounced exudative pleurisy and pericarditis, when a significant amount of fluid accumulates in the cavities, pleural and pericardial punctures can be indicated with removal of effusion.

Lifestyle with Dressler's syndrome

Patients with postinfarction syndrome should follow a healthy lifestyle that is necessary for all patients who underwent acute myocardial infarction. The following simple principles should be observed:

- healthy food - greater consumption of fresh fruits and vegetables, juices, fruit drinks, cereals and cereals, replacing animal fats with vegetable. It is necessary to limit the consumption of fatty varieties of meat and poultry, exclude coffee, carbonated drinks, fried, spicy, salty, spicy dishes, and cook food in boiled form or steamed. It is recommended to reduce the amount of salt consumed to 5 g per day, and the volume of liquid to be drunk - up to 1.5 liters per day;
- rejection of bad habits;
- early activation of the patient in bed in an acute period of infarction and moderate physical activity in the future. Already on the second - third day with a heart attack shows breathing exercises and exercise therapy under the supervision of a doctor in the position of lying in bed( with strict bed rest - movements of the hands, relaxation exercises), and then sitting and standing( with ward mode)5 - 10 minutes. With further sanatorium treatment, dosed walking, medical gymnastics, etc. are used.

Complications of

Complications with postinfarction syndrome practically do not develop, although single cases of severe kidney damage with the development of glomerulonephritis, and the defeat of vessels in the form of hemorrhagic vasculitis are described. Rarely, in the absence of hormonal treatment, the outcome of effusion of pericarditis in the adhesive pericarditis, which interferes with the relaxation of the heart muscle and promotes stagnation of blood in a large circle of circulation. Develops restrictive( diastolic) heart failure.

Forecast

The outlook for life is favorable.

Temporary disability( sick leave) in patients with Dresser's syndrome of myocardial infarction is defined for a period of 3 to 3.5 months, according to the indications, possibly longer.

Permanent disability( disability) is determined by the frequency of relapses, the degree of violations of cardiovascular functions caused not only by pleurisy, pericarditis and joint damage, but also by myocardial infarction. As a rule, Dressel's syndrome does not lead to disability.

Doctor therapist Sazykina O.Yu.