Rapid Review·Cardiovascular
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Cardiothoracic Surgery
T2High yieldPost-Cardiac Injury Syndrome
Focus on
Fever, pleuritic chest pain, a friction rub and an effusion weeks to months after cardiac surgery, PCI, a pacemaker lead, or an MI (when it is called Dressler syndrome) — an autoimmune reaction to exposed cardiac antigens. NSAIDs plus colchicine; aspirin instead of NSAIDs after an infarct; steroids only when refractory. Colchicine after surgery prevents it.
Key takeaways
What it is
Post-cardiac injury syndrome
an autoimmune febrile pericarditis or pleuritis after a cardiac event or intervention (bypass surgery, infarction, percutaneous intervention, device leads, ablation, chest trauma) that exposes the immune system to cardiac antigens.Names by setting
after an infarction it is called Dressler syndrome; after surgery, the postpericardiotomy syndrome.Not the early pericarditis
it is distinct from the early, direct-inflammation pericarditis of the first 1 to 3 days after an infarction.Clinical features and diagnosis
Timing
several weeks to months after the injury.Features
pleuritic chest pain, fever and leukocytosis, and a pericardial friction rub; sometimes a pleural rub, dyspnea, arthralgias.Effusion
signs of a pericardial effusion, and in a minority tamponade (more likely in anticoagulated post-operative patients).Clinical criteria
a recent cardiac injury plus at least two of these.- Fever without another cause.
- Pleuritic or pericarditic pain.
- A friction rub.
- A new or worsening pericardial effusion.
- A new pleural effusion.
- Raised inflammatory markers.
Imaging
echocardiography (a pericardial effusion is often present) and a chest radiograph (pleural effusion, an enlarged silhouette).Exclude
infection (mediastinitis, endocarditis), recurrent ischemia and pulmonary embolism.| Peri-infarction pericarditis | Dressler syndrome | Postpericardiotomy syndrome | Purulent pericarditis or mediastinitis | |
|---|---|---|---|---|
| Timing | 1 to 3 days after infarction | 2 to 10 weeks after infarction | 1 to 6 weeks after surgery or a procedure | Days to 2 weeks after surgery |
| Mechanism | Direct extension of inflammation over the infarct | Autoimmune | Autoimmune | Bacterial |
| Features | Localized rub, pleuritic pain, no fever | Fever, malaise, rub, diffuse ST elevation, effusion | Fever, rub, pericardial and pleural effusion, high inflammatory markers | High fever, rigors, purulent wound, unstable sternum |
| Treatment | High-dose aspirin; no other anti-inflammatory drugs or steroids for 7 days (rupture risk) | Aspirin plus colchicine | Non-steroidal anti-inflammatory drug plus colchicine | Drainage, debridement, intravenous antibiotics |
Management and prognosis
First line
a non-steroidal anti-inflammatory drug (ibuprofen) plus colchicine; colchicine for 3 months reduces recurrence.- Restrict strenuous activity until symptoms and markers settle.
After an infarction, aspirin is preferred
it is the antiplatelet already indicated, and the other anti-inflammatory drugs impair infarct healing.Corticosteroids for refractory cases
they work but raise recurrence, so second line.Effusion
pericardiocentesis for tamponade; a pericardial window for recurrent effusion.Prevention
colchicine after cardiac surgery (about a month) halves the incidence of the syndrome and of post-operative atrial fibrillation.Prognosis
typically self-limited over weeks; recurrence in 10 to 15 percent; tamponade (especially on anticoagulants).- A small percentage with chronic recurrences develop constrictive pericarditis (Constrictive Pericarditis).
Four weeks after bypass surgery, a patient has fever, pleuritic chest pain, a pericardial rub and a new left pleural effusion; the sternal wound is clean. What is the diagnosis and the first-line treatment?
Postpericardiotomy (post-cardiac injury) syndrome: autoimmune, weeks after surgery. Treat with a non-steroidal anti-inflammatory drug plus colchicine (aspirin instead if it follows an infarction); steroids only if refractory.
How it's tested
Four weeks after aortic valve replacement a man has fever, sharp chest pain worse lying down, a friction rub, a new left pleural effusion and a CRP of 90: post-cardiac injury (postpericardiotomy) syndrome — NSAIDs plus colchicine after excluding infection.
Three weeks after an MI: fever, pleuritic pain, diffuse ST elevation and a small effusion: Dressler syndrome — high-dose aspirin (not ibuprofen) plus colchicine.
Same picture but on day 2 after the MI with a localized rub and no fever: early peri-infarction pericarditis — aspirin; avoid NSAIDs and steroids for a week because of rupture risk.
Postpericardiotomy patient on warfarin becomes hypotensive with distended neck veins: hemorrhagic effusion with tamponade — echo and pericardiocentesis.
How can the syndrome be prevented after cardiac surgery: perioperative colchicine.
Go deeper
Guidelines: 2025 ESC Myocarditis and Pericarditis Guideline
Related Step 2 pages: Acute Pericarditis, Post MI Complications, Coronary Artery Bypass Grafting, Pericardial Effusion, Cardiac Tamponade, Constrictive Pericarditis, Sternal Dehiscence & Mediastinitis
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