Postmyocardial Infarction Syndrome

What is Postmyocardial Infarction Syndrome?

Postmyocardial infarction syndrome (PMIS), also called Dressler syndrome, is a form of secondary pericarditis, with or without fluid around the heart, that follows injury to the heart such as a heart attack.^[1] It belongs to a group of inflammatory pericardial conditions called post-cardiac injury syndromes, which also include inflammation after heart surgery.^[2]

Common symptoms

The main symptom is chest pain from the inflamed pericardium. It is typically sharp, worse with deep breaths or lying flat, and often better sitting forward.^[3] Fever, fatigue and a general unwell feeling can accompany it, and fluid around the heart or lungs may cause breathlessness.

Dressler syndrome should be considered in anyone with ongoing tiredness or malaise after a heart attack, especially when symptoms begin more than two weeks after the event.^[1] Because chest pain after a heart attack can also mean a new heart problem, it always needs urgent medical assessment.

Causes and risk factors

The cause is not fully settled, but it is thought to be an inflammatory, immune-related reaction after heart muscle injury.^{[1, 2]} It is not a common condition.^[1]

How it is diagnosed and treated conventionally

Your doctors diagnose it from your history of heart attack, your symptoms, a physical examination, an electrocardiogram, blood markers of inflammation and an echocardiogram to look for fluid.^{[2, 3]} Tests such as troponin may be repeated to make sure the pain is not another heart attack. Only your medical team can make this diagnosis.

Treatment follows the approach for pericarditis. High-dose NSAIDs are tapered as pain settles, and a course of colchicine is added to relieve symptoms and reduce recurrence.^[3] Corticosteroids and interleukin-1 blockers are used in selected cases, with caution after a heart attack.^{[2, 3]} A meta-analysis of 10 trials of colchicine in pericarditis and post-pericardiotomy syndrome found fewer recurrences and more side effects, mostly digestive.^[4] Fluid that threatens the heart is drained.^[5]

Why Postmyocardial Infarction Syndrome calls for a whole-person approach

PMIS is a medical complication that needs medical treatment. Recovery from a heart attack, though, involves more than the pericardium. Worry about the heart, poor sleep, tiredness and the side effects of several medicines all affect how a person feels.

Supportive care can address those parts of recovery. It cannot treat the inflammation or replace the anti-inflammatory and heart medicines your cardiologist chooses.

Inflammation after heart injury

Inflammation is central. After a heart attack, the immune system responds to damaged tissue, and in PMIS that response reaches the pericardium. Doctors must balance calming this inflammation against allowing the heart muscle to heal.^[2]

Stress, sleep and mood during recovery

Living through a heart attack is stressful, and sleep and mood often suffer afterward. Supportive care for sleep and stress is a reasonable part of recovery as long as it does not interfere with cardiac treatment, although the sleep research below was not done in heart patients.^[6]

Medicines and bleeding risk

Many people recovering from a heart attack take blood thinners. NSAIDs given for pericarditis add to bleeding risk with anticoagulants, which is why herbs and supplements need extra care in this group.^[7]

Acupuncture as supportive care in Postmyocardial Infarction Syndrome

What the research shows

We found no clinical trials of acupuncture in postmyocardial infarction syndrome, so we cannot say it helps the syndrome.

Studies in related heart conditions are indirect and of low quality. A systematic review of 16 studies in angina found that acupuncture, alone or with drugs, relieved angina symptoms and improved electrocardiogram findings, but the studies had a moderate or high risk of bias. The review also noted that acupuncture acts too slowly to be suitable for emergency treatment of a heart attack.^[8] These results cannot be applied to pericarditis.

For sleep, a review of 24 trials in insomnia included a meta-analysis of 15 trials that suggested acupuncture improved sleep scores more than medication after about three weeks, with large variation between studies.^[6] This research was not in heart patients.

How acupuncture may work

We found no research on how acupuncture might act in PMIS, and no study showing that it changes pericardial inflammation. Any explanation of how it works in this syndrome would be speculation.

What treatment involves

Treatment uses fine, sterile, single-use needles at selected points, typically left in place for about 20 to 40 minutes. A course involves several visits with reassessment. Points on the arms, legs and ears are often used, and needling over the chest is not required.

Serious problems are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[9] Case reports describe cardiac tamponade when needles were placed close to the heart, so anyone with fluid around the heart should tell the practitioner and avoid needling over the chest.^[10] Tell the practitioner first if you have a bleeding disorder, take blood thinners or antiplatelet drugs, are pregnant, or have a pacemaker or defibrillator (relevant to electroacupuncture).

Ayurvedic medicine as supportive care in Postmyocardial Infarction Syndrome

The Ayurvedic view

Ayurveda has no classical name for this complication. Traditional practitioners describe heart disease in terms of imbalance of the three doshas, and inflammation with fever and pain as aggravated Pitta. These are traditional frameworks, not biomedical diagnoses.

Therapies that may be used

Within a supportive role, care might include:

• Diet and daily routine advice, such as regular warm meals and steady sleep hours, in line with the heart-healthy diet and any fluid or salt limits from your cardiology team
• Gentle relaxation and breathing practices for stress and sleep, if your cardiac team agrees
• Gentle oil massage, avoiding the chest while it is tender

Panchakarma procedures are not appropriate during recovery from a heart attack, acute illness, fever or frailty, so they are not a sensible option for PMIS.

What the research shows

We found no studies of Ayurvedic medicine in PMIS. The evidence is therefore none for this condition.

Product quality is a documented concern: about one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[11] Ayurvedic herbs are also herbal medications, so the cautions about interactions with heart and blood-thinning medicines in the herbal section below apply to them as well.^[12]

Herbal medicine as supportive care in Postmyocardial Infarction Syndrome

Herbs and formulas that have been studied

We found no clinical studies of any herb or formula for PMIS. Chinese patent medicines have been studied in heart attack itself, mostly in China, including Tongxinluo, Danhong injection and Shexiang Baoxin pill.^{[13, 14]}

What the research shows

There is no clinical evidence that herbal medicine treats PMIS. In the large Tongxinluo trial, 3,777 people with a STEMI heart attack took either the compound or a placebo along with standard care, and fewer in the Tongxinluo group had major cardiac events at 30 days and one year, though more had adverse drug reactions, mostly digestive.^[13] A network meta-analysis of 160 trials found no significant effect of any Chinese patent medicine on major cardiovascular events, only on intermediate measures such as blood flow after stenting and angina, with low to moderate certainty.^[14]

These are studies of heart attack outcomes, not of Dressler syndrome, and we do not offer herbs as a treatment for either.

Safety and herb-drug interactions

Herbs can interact with the drugs used after a heart attack. Case reports describe enhanced bleeding when warfarin or aspirin was combined with Salvia miltiorrhiza (dan shen), garlic or ginkgo.^[15] A systematic review found that 45 herbs, foods and supplements were reported to potentiate warfarin.^[16] Herbs may also affect the heart rhythm and blood pressure.^[12]

NSAIDs for pericarditis raise bleeding risk further with blood thinners.^[7] Please tell us about all of your medicines, including colchicine, steroids, antiplatelets and anticoagulants, and about pregnancy, breastfeeding, and liver or kidney disease. Any herb should be checked with your cardiologist first.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine would describe a heart attack and its aftermath in terms of blood stasis, qi deficiency or heat in the chest, and Ayurveda would speak of Pitta and Vata imbalance. Researchers describe an immune and inflammatory reaction to heart muscle injury that reaches the pericardium.^{[1, 2]}

Some research on "blood-activating" Chinese formulas looks at blood flow and angina after heart attack, which loosely parallels the idea of blood stasis.^[14] No study has shown that a traditional pattern matches a measurable process in PMIS.

How this care fits with your medical care

PMIS needs a cardiologist. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care. We offer supportive care only after the condition is under medical management.

Keep taking prescribed heart medicines, anti-inflammatory drugs and colchicine, and keep your follow-up visits and echocardiograms. Please bring your diagnosis, recent test results, your cardiologist's contact details and your full list of medicines and supplements. We do not diagnose PMIS, prescribe or change drugs, or advise stopping any heart medicine.

When to seek urgent medical care

Chest pain after a heart attack can signal pericarditis, a new heart attack, or fluid pressing on the heart, and only tests can tell them apart.^{[1, 3]}

• New or worsening chest pain, especially pain lasting more than a few minutes or spreading to the arm, jaw or back
• Increasing shortness of breath, or needing to sit upright to breathe
• Fainting, dizziness, a racing heartbeat or very low blood pressure
• Fever that does not settle
• Swelling of the legs, abdomen or neck veins
• Black stools or vomiting blood while taking anti-inflammatory medicines and blood thinners

If you have severe chest pain, fainting or severe breathlessness, call 911 or go to the nearest emergency department.