Post cardiac injury syndrome
Synonyms and keywords: PCIS

# Overview
Post cardiac injury syndrome (PCIS) encompasses three causes of pericarditis: Post myocardial infarction syndrome (PMIS) or Dressler's syndrome, Postpericardiotomy syndrome (PCS) and Posttraumatic pericarditis.

# Historical Perspective
- Dressler's syndrome was first discovered by William Dressler, a Jewish-American Cardiologist at Maimonides Medical Centre, in 1956.
- Postcommissurotomy syndrome, initially described in 1952 in patients undergoing mitral valve surgery.  It was later renamed to Postpericardiotomy syndrome in 1958. 

# Classification

# Pathophysiology
Both syndromes represent the delayed occurrence of pericarditis. Post-myocardial infarction syndrome is obviously due to myocardial infarction and postpericardiotomy syndrome is due to the myocardial injury that occurs during cardiac surgery. The initial trigger seems to be the combination of damage occurring to the pericardial or pleural mesothelial cells and blood entering the pericardial space which causes the release of cardiac antigens into the circulation. It leads to the formation of immune complexes which get deposited into the pericardium, pleura, lungs, joints etc eliciting an inflammatory response. 

# Clinical Features
Specific symptoms of post-cardiac injury syndrome include:
- Pleuritic chest pain
- Fever
- Elevated markers of inflammation
- Pericardial effusion
- Pleural effusion
- Pulmonary infiltrates

# Differentiating Post cardiac injury syndrome from other Diseases
- PCIS must be differentiated from other diseases that cause fever, chest pain and pleuropericardial effusion, such as:
- Pleuritis or Pleuropericarditis
- Pulmonary embolism
- Boerhaave Syndrome
- Blunt chest wall trauma
- Pneumothorax
- Connective tissue disorders (e.g SLE)

# Epidemiology and Demographics
- Incidence: Dressler's syndrome was reported to occur in about 3 to 4% of MI cases. Now it has been markedly decreased due to improvements in the management of Myocardial infarction which result in the small infarct size whereas postpericardiotomy syndrome has been reported in 10 to 40% of patients after cardiac surgery.

## Age
- Dressler's syndrome occurs more often in younger age groups.
- The risk of postpericardiotomy syndrome (PPS) increases with age.

## Gender
- Female gender is an independent risk factor for postpericardiotomy syndrome.

## Race
- There is no racial predilection for post cardiac injury syndrome.

# Risk Factors
These are the factors which increase the risk of post cardiac injury syndrome: 
- Cardiac Surgery (including AVR, MVR and aortic surgery)
- Young age
- Previous pericarditis
- Viral Infection
- Prior treatment with prednisone
- Blood type B negative
- Halothane anesthesia

# Natural History, Complications and Prognosis

## Natural History
- Post cardiac injury syndrome usually occurs in 1 to 6 weeks after initial pericardial injury.
- Most patients presents with fever which subsides within 2-3 weeks.

## Complications
Rare complications include the development of:
- Cardiac tamponade
- Pericardial constriction
- Saphenous vein graft occlusion

## Prognosis
- Post cardiac injury syndrome has relatively a good prognosis.
- The recurrence rate is reported to be 10-15% but has a small risk of developing constrictive pericarditis which requires a long term follow-up.

# Diagnosis

## Diagnostic Criteria
- Dressler syndrome typically occurs 12 weeks after STEMI. Its diagnostic criteria do not differ from those for acute pericarditis including two of the following criteria: (i)  Pleuritic chest pain; (ii) Pericardial friction rub; (iii) ECG changes (new widespread ST-segment elevation and PR depressions in multiple leads (except for aVR and V1); and (iv) Pericardial effusion.
- Diagnostic criteria for Postpericardiotomy Syndrome include the presence of at least two of the following five symptoms: (i) new or worsening pleural effusion, (ii) new or worsening pericardial effusion, (iii) fever without alternative causes, (iv) pleuritic chest pain, and (v) pleural or pericardial rubbing

## Symptoms
Both syndromes share common symptoms which include fever and pleuritic pain.

## Physical Examination
The following findings may be present:

### Cardiovascular
A pericardial friction rub

### Lungs
A pleural effusion

## Laboratory Studies
The following lab abnormalities may be present:
- An elevated erythrocyte sedimentation rate.
- A leukocytosis.

## Chest x-ray
A pleural effusion with or without pulmonary infiltrates may be present.

## Electrocardiogram
The change of ECG from the baseline and showing the following findings can be suggestive of pericarditis:
- Diffuse ST-segment elevation with PR depression

## Echocardiography
It can be used to
- Determine the presence or absence of pericardial effusion and
- Rule out the possibility of cardiac tamponade.

## Cardiac MRI
To assess the posterior pericardium, which is difficult to visualize with the echocardiogram.

# Treatment
Dressler's syndrome is typically treated with high dose (up to 650 mg PO q 4 to 6 hours) enteric-coated aspirin.  Acetominophen can be added for pain management as this does not affect the coagulation system.  Anticoagulants should be discontinued if the patient develops a pericardial effusion.
NSAIDs such as ibuprofen should be avoided in the peri-infarct period as they:
- Increase the risk of reinfarction
- Adversely impact left ventricular remodeling.
- Block the effectiveness of aspirin

# Treatment

## Medical Therapy
- The mainstay of therapy for postcardiac injury syndrome is Anti-inflammatory NSAIDs in combination with colchicine. 
- Aspirin is preferred in postmyocardial infarction pericarditis.
- Recurrent cases can be treated with glucocorticoids in combination with aspirin and colchicine.

## Surgery
- Surgical intervention is not recommended for the treatment of post cardiac injury syndrome.
- Pericardiocentesis with catheter drainage is considered the standard of care for patients with a significant pericardial effusion due to complications of PCIS (i.e cardiac tamponade or constrictive pericarditis).

## Prevention
- Colchicine significantly reduces the incidence of post cardiac injury syndrome.

## ACC/AHA Treatment Guidelines (DO NOT EDIT)

# Sources
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction 
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction