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cardio.cardiac-tamponade.dressler-syndrome.v1

Cardiac tamponade — Dressler syndrome (post-cardiac-injury syndrome)

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Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to Dressler syndrome / post-cardiac-injury syndrome (PCIS), the modern umbrella term for this autoimmune pericarditis 2-12 weeks (median 3-6 wk) following acute myocardial injury (post-MI especially without timely reperfusion, post-CABG / valve / thoracic surgery, post-pacemaker / ICD lead implant, post-AF ablation, post-PCI with myocardial perforation, post-blunt cardiac trauma). Incidence ~1-3% post-MI and 5-15% post-cardiac-surgery per CIRCS / COPPS / COPPS-2 trials. Clinical: ≥2 of 5 PCIS criteria — fever (low-grade), pleuritic chest pain (worse supine, better leaning forward), pericardial / pleural friction rub, pericardial / pleural effusion, elevated CRP. Tamponade physiology in ~10-20% of cases (subacute as effusion accumulates over days-weeks; can be hyperacute if rapid bleed in post-PCI / DAPT / anticoagulation context). First-line therapy: high-dose ASA 750-1000 mg PO TID × 1-2 wk (PREFERRED post-MI given continued antiplatelet benefit) OR ibuprofen 600 mg TID × 1-2 wk (alternative if post-surgery / non-MI / ASA intolerance) — both with PPI prophylaxis + slow CRP-guided taper over 6-8 wk total; PLUS colchicine 0.5 mg PO BID × 3 mo (CORNERSTONE per CORP / CORP-2 / ICAP / COPPS-2 — RR 0.56 recurrence reduction) — ALWAYS combined. Corticosteroids RESERVED for refractory or first-line contraindication — prednisolone 0.2-0.5 mg/kg/d (LOW dose; high-dose increases recurrence risk per CORP-2) with very slow 6-8 wk taper. Pericardiocentesis ONLY if tamponade. Cardiac MRI for refractory or complex cases. Azathioprine + anakinra (AIRTRIP Brucato JAMA 2016) for steroid-dependent refractory recurrent. Severity triggers cover tamponade physiology requiring emergent drainage, differential re-infarction vs Dressler in post-MI chest pain (HEART + serial troponin), refractory PCIS requiring corticosteroid escalation, multiple recurrent pericarditis with steroid dependence requiring biologic, hemorrhagic PCIS in post-PCI patient on DAPT / anticoagulation. Sister-differentiated from post-procedural (acute iatrogenic mechanical), post-TAVR (acute iatrogenic structural), and general pericarditis (variable etiology). Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (Dressler / PCIS-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (6)

  • symptom
    Low-grade fever + pleuritic chest pain (worse supine, better leaning forward) 2-12 weeks post-MI / post-CABG / post-pacemaker / post-ablation → Dressler syndrome / PCIS (ESC 2015 §Post-Cardiac Injury Syndrome; Imazio CIRCS NEJM 2015 PMID 26315582)
    fever_plus_pleuritic_chest_pain_2_to_12_wk_post_mi_or_cardiac_surgery
  • history
    Recent (2-12 wk) cardiac injury (MI, CABG, valve surgery, lead implant, ablation, blunt trauma) with new friction rub + ESR / CRP elevation (Imazio COPPS PMID 20447948)
    recent_cardiac_injury_with_friction_rub_and_elevated_inflammatory_markers
  • imaging
    Echo: new pericardial effusion 2-12 weeks post-cardiac-injury — variable size; tamponade physiology in ~10-20% of cases (ESC 2015 Class I; Imazio JAMA 2014 PMID 25268438)
    echo_new_pericardial_effusion_post_cardiac_injury
  • symptom
    Recurrent pericarditis pattern (recurrent fever + pleuritic chest pain + friction rub + ESR/CRP recurrence) post initial PCIS episode → multiple recurrences requiring colchicine + careful taper (Imazio CORP PMID 21788540)
    recurrent_pericarditis_pattern_post_initial_episode
  • lab_abnormality
    Elevated ESR + CRP in patient with recent (2-12 wk) cardiac injury history without alternative etiology → PCIS workup (Adler 2015 BMJ)
    elevated_esr_crp_with_recent_cardiac_history
  • history
    Hyperacute presentation in post-PCI patient on dual antiplatelet therapy + anticoagulation with sudden hemodynamic decompensation + new effusion → can be PCIS variant with bleeding component (ESC 2015)
    hyperacute_post_pci_or_anticoagulation_with_pericardial_effusion

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Older patients have higher post-MI Dressler risk + worse drug tolerance (Adler 2015 BMJ)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension is part of Beck triad if tamponade physiology develops (~10-20% of cases) (ESC 2015)
  • hrrequired
    vital • used at CONTEXT
    Compensatory tachycardia in tamponade physiology + low-grade tachycardia from inflammation (Imazio ICAP PMID 23992557)
  • temperaturerequired
    vital • used at INITIAL_WORKUP
    Low-grade fever (typically 37.5-38.5°C) is a hallmark — present in ~70-80% of cases (Adler 2015 BMJ)
  • echorequired
    imaging • used at INITIAL_WORKUP
    Definitive bedside dx — chamber collapse, IVC, swinging heart if tamponade; effusion size + character drives drainage decision (ESC 2015 Class I)
  • cardiac_injury_type_and_timingrequired
    history • used at CONTEXT
    MI vs CABG vs valve surgery vs lead implant vs ablation vs trauma; days-weeks elapsed since injury — drives diagnosis confidence + therapy selection (ASA preferred post-MI vs NSAID acceptable post-surgery) (ESC 2015; Imazio CIRCS PMID 26315582)
  • antiplatelet_and_anticoagulation_statusrequired
    history • used at CONTEXT
    DAPT / DOAC / warfarin status drives hemorrhagic component risk + NSAID safety + pericardiocentesis bleeding risk (ESC 2015)
  • crprequired
    lab • used at INITIAL_WORKUP
    CRP elevation is a key diagnostic criterion + treatment response marker; trend to <1 mg/dL guides therapy de-escalation (Imazio ICAP PMID 23992557)
  • wbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis present in ~60-70% of cases; supports diagnosis when other criteria present (Adler 2015 BMJ)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Baseline for NSAID + colchicine renal dose adjustment (CrCl <30 → avoid colchicine) + ASA renal safety (ESC 2015)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Often mildly elevated from associated myopericarditis component; helps differentiate from re-infarction (Adler 2015 BMJ)

12-phase flow (9)

  1. 1FRAME
    Dressler syndrome / PCIS — autoimmune pericarditis 2-12 wk post-cardiac-injury; high-dose ASA + colchicine first-line (preferred post-MI); NSAIDs + colchicine alternative (post-surgery); corticosteroids reserved for refractory; pericardiocentesis only if tamponade (~10-20% of cases) (ESC 2015 §Post-Cardiac Injury Syndrome; Imazio CIRCS NEJM 2015 PMID 26315582)
    inputs: sbp
    advance: PCIS context with appropriate timing post-injury suspected
  2. 2ENTRY
    Recognize ≥2 of 5 PCIS criteria: (1) fever without alternative cause; (2) pleuritic chest pain; (3) pericardial / pleural friction rub; (4) pericardial effusion or pleural effusion (with elevated CRP); (5) elevated CRP. Timing: 2-12 wk post-cardiac-injury (Imazio ICAP; ESC 2015)
    inputs: age
    advance: ≥2 of 5 PCIS criteria met + appropriate timing post-injury
  3. 3CONTEXT
    Document cardiac injury type + timing + reperfusion status, current antiplatelet / anticoagulation regimen, prior pericarditis episodes, comorbidities affecting drug tolerance (CKD, GI bleeding history, peptic ulcer disease), pregnancy status (NSAIDs contraindicated late pregnancy) (ESC 2015)
    inputs: cardiac_injury_type_and_timing, antiplatelet_and_anticoagulation_status
    advance: PCIS context fully captured
  4. 4RED_FLAGS
    Tamponade physiology in ~10-20% of PCIS cases — recognize Beck triad + pulsus paradoxus; hyperacute presentation in post-PCI / DAPT context can have hemorrhagic component requiring emergent drainage + reversal (ESC 2015; Imazio JAMA 2014 PMID 25268438)
    inputs: sbp, hr
    advance: tamponade vs uncomplicated PCIS triaged
  5. 5INITIAL_WORKUP
    STAT echo, ECG (diffuse PR depression / ST elevation if active pericarditis), CXR, CRP, ESR, CBC with diff, BMP, troponin (often mildly elevated), coags if drainage anticipated; differentiate from re-infarction with serial troponin + cath if concern (ESC 2015; Adler 2015 BMJ)
    inputs: echo, crp, wbc, creatinine, troponin, temperature
    actions: panel.cardiac, panel.renal, panel.cbc
    advance: echo + inflammatory markers + cardiac biomarkers documented
  6. 6DIFFERENTIAL
    Differentiate PCIS from: (1) re-infarction (serial troponin trend + cath if rising); (2) infectious pericarditis (no fever pattern + elevated procalcitonin + positive cultures); (3) malignant effusion (cancer history + cytology); (4) uremic pericarditis (CKD context + BUN >100); (5) post-procedural bleeding (no inflammatory markers, anticoagulation context). Pericardial fluid analysis ONLY if tamponade requiring drainage (ESC 2015; Adler 2015 BMJ)
    advance: PCIS confirmed by clinical criteria + alternatives excluded
  7. 7TREATMENT
    Step 1 high-dose ASA 750-1000 mg PO TID × 1-2 wk THEN taper by 250-500 mg every 1-2 wk per CRP normalization (PREFERRED post-MI given antiplatelet benefit) OR ibuprofen 600 mg PO TID × 1-2 wk then taper (alternative if post-surgery / non-MI context); Step 2 colchicine 0.5 mg PO BID × 3 mo (ALWAYS combined with ASA / NSAID — RR 0.56 reduction in recurrence per CORP-2 + ICAP); Step 3 corticosteroids RESERVED — prednisolone 0.2-0.5 mg/kg/d with slow taper over weeks ONLY if refractory despite ASA/NSAID + colchicine OR contraindication; Step 4 pericardiocentesis ONLY if tamponade with hemodynamic compromise; Step 5 cardiac MRI for refractory or complex cases (gadolinium uptake confirms active inflammation); Step 6 reverse anticoagulation if hemorrhagic component + drainage required (ESC 2015; Imazio CORP-2 PMID 24239018; Imazio ICAP PMID 23992557)
    inputs: sbp
    advance: first-line therapy initiated + drainage performed if tamponade
  8. 8DISPOSITION
    Outpatient management for stable PCIS without tamponade; admission for tamponade or refractory pain or comorbidity; cardiology + (if applicable) cardiothoracic surgery follow-up; cardiac MRI if refractory or complex (ESC 2015)
    advance: disposition based on tamponade status + symptom severity confirmed
  9. 9MONITORING
    CRP trend (target normalization to <1 mg/dL guides therapy de-escalation), echo at 1 wk + 4 wk + 12 wk for resolution + recurrence surveillance, drug tolerance (GI side effects from NSAIDs / ASA, colchicine GI toxicity, steroid side effects if used), recurrence pattern (Imazio CORP / CORP-2 PMID 21788540 / 24239018; Imazio ICAP PMID 23992557)
    actions: panel.cardiac
    advance: CRP normalized + symptoms resolved + recurrence surveillance ongoing