POSTINFARCTION SYNDROME (Latin post after +infarctus, from infarcire to fill; the syndrome) — the collective concept relating to diverse manifestations of peculiar complications of an acute myocardial infarction for to-rykh is supposed the general their autoimmune genesis.
Carry the pericardis, pleurisy or a polyserositis which are developing in 2 — 8 weeks after development of a myocardial infarction and followed by fever and an eosinophilia to typical manifestations of P. of page. Less typical manifestations — pneumonia, the isolated allergic peritonitis, a scapularhumeral syndrome, or a syndrome of a shoulder (arthritis of a shoulder joint with pain and restriction of the movement), and also a so-called syndrome of a front chest wall (pain in muscles of a thorax) which carry to P. page at their development in the specified terms, especially, if they are followed by fever, resistant to antibacterial therapy, an eosinophilia or are combined with typical manifestations of P. of page. There is a tendency to carry to P. page any presumably immunopathological manifestations (arthralgias, skin rashes, attacks of bronchial asthma, some hematologic syndromes, hepatitis, etc.) which are chronologically connected with a myocardial infarction.
The late pericardis after a myocardial infarction was described in 1953 Mr. Faure and Kazey (L. Faure, M. of Cazeilles), but they considered it an acute returnable benign pericarditis and only assumed possible communication with the postponed myocardial infarction.
In 1955 W. Dressier for the first time allocated in an independent syndrome emergence of a late serositis (a pericardis, pleurisy), fevers and eosinophilias, having connected them with autoallergichesky reaction to the proteins of a myocardium changed owing to a heart attack. Designation of typical manifestations of P. of page as W. Dressier's syndrome is explained by it.
In the USSR P. page is described by A. M. Damir, A. P. Matusova in 1961, in the subsequent most in detail it was studied by P. N. Yurenev with sotr.
P.'s frequency of page is estimated differently; because of an illegibility of diagnostic criteria and smaller probability of the correct diagnosis in cases when P. of page develops after an extract of the patient from a hospital, it is very difficult to establish the frequency of emergence of P. of page. The typical developed forms of a syndrome of W. Dressier are rare and are observed, according to different data, at 1 — 4% of the patients who transferred myocardial infarction (see). The clinical physicians including page and atypical or oligosymptomatic forms in P. report about its more high frequency reaching 14,8 and even 22,7%, but not always with sufficient differentiation with other forms of pathology.
the Aetiology is considered within a causal relationship of development of P. of page with the necrosis and hypoxemic damage (in a periinfarktny zone) a myocardium leading to formation of the changed proteins capable to sensibilize an organism. There is an opinion that P.'s development by page does not depend on size and weight of a course of a myocardial infarction; however, usually it is observed at extensive damages of heart. Communication of a postinfarction pericardis with epistenokardichesky is possible; according to Fridberg (S. K. of Fried-berg), it is more often noted in cases when the pericardis took place and in the most acute period of a disease.
It was suggested that P. the page has a virus etiology. According to Bertsch (G. E. Burch), a myocardial infarction can reactivate a latent viral infection, edges the page is clinically shown as P. Fever, pain, a pericardiac exudate, acceleration of ROE, inefficiency of antibiotics are characteristic of diseases of virus genesis. However there are no messages on allocation of a virus from blood, a pericardiac or pleural exudate at P. page.
the Pathogeny is connected with processes of autoimmunization. The assumption of such communication is based first of all that a wedge, P.'s manifestations by the village are characteristic of the diseases having the immune nature. It is confirmed and positive effect of glucocorticosteroid therapy. A basis of a pathogeny of P. of page is probably the mechanism of hypersensitivity of the slowed-down type to antigen, the Crimea becomes the damaged tissue of heart. Dressler, and also Berman and Grismer (L. A. Berman, J. T. Grismer) found in lungs and a myocardium of certain patients with P. page gistopatol. the changes characteristic of the slowed-down hypersensitivity — histiocytic proliferation and perivascular a circle-lokletochnuyu infiltration. There are no other direct instructions on the autoimmune nature of P. of page. Anticardial antibodies at P. of page can be absent (more often their caption does not differ from usually found at an uncomplicated myocardial infarction), but it does not contradict ideas of the autoimmune nature of P. of page since antibodies can be fixed by fabrics. At P. of page decrease in immunoglobulins G and considerable reduction of rosette-forming cells is revealed. These shifts are interpreted as manifestation of deficit, dysfunction of immunity, a cut can be also connected with development of autoimmune states.
The pathological anatomy
Pathological anatomy is not characterized by any specific changes. The pericardiac exudate in those exceptional cases when its removal was required, more often turned out hemorrhagic that connected with spread of a heart attack under an epicardium or using anticoagulants. When investigated the liquid taken later considerable time after a myocardial infarction found out that it contains preferential neutrophilic polymorphonuclear leukocytes. In some cases took place gistopatol. the changes characteristic of allergic reactions of the slowed-down type (see. Allergy ).
The clinic and the diagnosis
the pages, Most specific to P., are a pericardis and pleurisy (or a polyserositis) in combination with other, less obligatory manifestations — pneumonia (pulmonitis), arthritis, dermatitis, etc. As a rule, typical P. of page develops on 2 — 4th week of a myocardial infarction or later, but certain patients have a combination of pleurisy and a pericardis it is noted already on 2 — the 3rd days that allows to speak about so-called early P.'s possibility of page.
Pericardis (see) — the main clinical implication of P. of page — usually begins with emergence of pain in heart and a pericardial rub. Unlike observed at an epistenokardichesky pericardis a friction murmur keeps long enough — up to several days and more. The exudate is formed usually in a small amount and often can be found only at tool researches. Occasionally the exudate happens massive and can lead to a circulatory unefficiency. In an acute phase of a pericardis characteristic changes of an ECG — the shift of segments of ST above the izoelektriche-sky line are observed, change of a tooth of T. Sochetaniye of pain and changes of an ECG can lead to the assumption of distribution or developing of a repeated myocardial infarction. Differential diagnosis is carried out on the basis of the analysis of the features of a pain syndrome distinguishing it from the displays of stenocardia at this patient given researches of activity of enzymes (a kreatinfosfo-kinase, a lactate dehydrogenase, aminotransferases) in blood serum and features by the ECG loudspeakers. The current of a pericardis differs in tendency to recuring.
Pleurisy (see), usually left-, is more rare bilateral, often accompanies defeat of a pericardium, but maybe independent. It is shown by the thorax pain amplifying at deep breath, a pleural rub. Accumulation of the exudate containing many lymphocytes or eosinophils is possible. The amount of liquid, as a rule, small, and its removal is required seldom. The current is favorable, but it is frequent with a recurrence. Formation of commissural process is in some cases possible.
Rare manifestation polyserositis (see) at P. the defeat of a peritoneum which is followed by abdominal pains and symptoms of peritonitis can be page. Existence eosinophilias (see) and especially the combination to a pericardis or pleurisy allows to regard these symptoms as P.'s manifestation by the village.
Pneumonia at P. can accompany with page defeat of serous covers or proceed separately. Prevalence of process happens various up to massive bilateral, but limited melkoochagovy defeat is more characteristic. Any specific clinical or radiological characters, except inefficiency of antibiotics, no. The pneumorrhagia which is observed at nek-ry patients demands an exception of a thromboembolism of branches of a pulmonary trunk with a heart attack of lungs.
Listed typical a wedge, P.'s manifestations by the village usually are followed by temperature increase, during the first hours of emergence of a serositis can reach edge 38 — 39 °, but more often happens subfebrile and the long time keeps. In blood neutrophylic is observed leukocytosis (see), acceleration of ROE; it is possible, but is not obligatory, the expressed eosinophilia.
Less typical manifestation of P. of page — damage of joints (an arthralgia, mono - and polyarthritises) — is described as option P. of page and into the forefront in a wedge, to a picture acts seldom. Perhaps, emergence of a so-called syndrome of a shoulder (the humeral syndrome, a syndrome of a hand) described as an independent form P. of page is explained by arthritis of a shoulder joint.
The syndrome of a shoulder or hand is expressed by a constant omalgia (more often in left, sometimes in both) probably caused by a periarthritis, leading to restriction of movements in a joint and even to development of rigidity. Along with it puffiness of a brush, swelling of joints of fingers of hands can be noted. Statistically the frequency of this syndrome in 70 — steadily decreased the 80th therefore it meets seldom. It is connected with considerable acceleration of activation of patients since consider that in an origin of a syndrome of a shoulder an important role is played by inaction of a shoulder joint. Apparently, to relatives also the so-called syndrome of a front wall of a thorax which is also carried to P. by pages by origin is. It is shown by pains in muscles of a thorax in front, usually at the left, and morbidity in the same place at a palpation that distinguishes these pains from stenocardia. It is difficult to verify the relation of these symptoms to P. of page; often they not otlichima from the complaints caused by various neurotic reactions. However when syndromes of a shoulder or a front wall of a thorax are followed by fever, a leukocytosis, an eosinophilia and especially signs of a serositis, consider them as P.'s manifestation by the village and explain with developing of arthritis and damage of a periosteum of edges.
In group of atypical and oligosymptomatic manifestations of P. of page refer long inexplicable temperature increase, the isolated leukocytosis and an eosinophilia, and also various skin changes in a look dermatitis (see), eczemas (see), erythema (see), small tortoiseshells (see) which it is possible to carry page to P. more surely if they are combined with a serositis. In other cases it must be kept in mind a possibility of other etiology of these symptoms, first of all medicinal and infectious. As rare forms P. of page are described autoimmune hepatitis, bronchial asthma, an acute glomerulonephritis, a hemorrhagic vasculitis, a Werlhof's disease with anemia and a leykotsitopeniya.
Diagnosis of oligosymptomatic and atypical manifestations of P. of page is always difficult. Suspicion on P. of page shall arise at emergence of fever, resistant to antibiotics of pneumonia, arthralgias, skin rash etc. if they appeared in the first months after a myocardial infarction. In all these cases it is necessary to look for precisely signs of a serositis, napr, a pericardiac exudate with the help Echocardiography (see). From a lab. indicators a nek-swarm diagnostic value has detection of an eosinophilia. As diagnostic test in doubtful cases also Prednisolonum which is applied for this purpose in a dose of 30 — 40 mg within 3 — 5 days can be used.
Forecast at P. favorable for life, but in case of high fever and at big exudates in serous cavities conditions of additional load of a hemodynamics are created to page that can worsen the forecast of the main disease — a myocardial infarction.
Treatment consists in use of glucocorticoid hormones, in particular Prednisolonum which in typical cases is appointed at first in doses by 40 — 80 mg. In process of reduction of a pain syndrome, decrease in temperature and disappearance of a leukocytosis the dose of drug is gradually reduced. The maintenance therapy can be continued by small doses (5 — 15 mg) of Prednisolonum within several weeks, and at the developed typiforms longer. In the presence of contraindications to use of glucocorticoids use other immunodepressants. There are messages on successful use of antimetabolites — 6 Mercaptopurinum, Azathioprinum.
As symptomatic therapy for anesthesia appoint salicylates, indometacin, analginum.
Bibliography: Yurenev P. N. Postinfarction syndrome, Cardiology, t. 14, No. 7, page 73, 1974; Yurenev P. N. and Semenovich N. I. Clinic and therapy of allergic damages of heart and vessels, M., 1972; Dressier W. The post-myocardial-infarction syndrome, Arch, intern. Med., v. 103, p. 28, 1959; K o s-sowsky W. A., Epstein P. J. a. Levine R. S. Post myocardial infarction syndrome, Chest, v. 63, p. 35, 1973.
H. A. Gratsiansky.