What is the treatment for ST elevation myocarditis?

Treatment for ST Elevation Myocarditis

The treatment for ST elevation myocarditis should focus on supportive care with aspirin as first-line therapy, with colchicine added for cases not adequately controlled with aspirin alone. 1

Initial Management

• Aspirin should be initiated as the primary anti-inflammatory treatment for ST elevation myocarditis presenting with pericarditis 1
• Cardiac imaging with echocardiography should be performed during hospital stay to assess ventricular function, detect mechanical complications, and exclude left ventricular thrombus 1
• Cardiac magnetic resonance imaging (MRI) is recommended for definitive diagnosis to differentiate myocarditis from true ST-elevation myocardial infarction 2
• Coronary angiography should be performed to rule out coronary artery disease, as myocarditis can mimic STEMI with similar ECG findings and elevated troponins 3, 4

Anti-inflammatory Therapy

• For cases not adequately controlled with aspirin, colchicine 0.6 mg every 12 hours orally is recommended as a reasonable addition 1
• Acetaminophen 500 mg orally every 6 hours can be added if pain control is inadequate with aspirin and colchicine 1
• Narcotic analgesics may be considered if pain remains uncontrolled despite aspirin, colchicine, and acetaminophen 1

Medications to Avoid

• Glucocorticoids and nonsteroidal anti-inflammatory drugs (NSAIDs) are potentially harmful for treatment of pericarditis after STEMI and should be avoided 1
• If NSAIDs must be used for pain relief, they should not be used for extended periods due to their effects on platelet function and increased risk of myocardial scar thinning and infarct expansion 1
• Corticosteroids should only be considered as a last resort in patients with pericarditis refractory to aspirin or other medications, as they are associated with increased risk of scar thinning and myocardial rupture 1, 2

Management of Complications

• For patients developing heart failure, ACE inhibitors are recommended within the first 24 hours 1
• Beta-blockers are indicated in patients with heart failure and/or LVEF < 40% unless contraindicated 1
• High-intensity statin therapy should be initiated or continued in all patients with no contraindications 1
• For patients with cardiogenic shock:
  • Emergency revascularization with either PCI or CABG is recommended if suitable 1
  • Intra-aortic balloon pump counterpulsation can be useful for patients who don't quickly stabilize with pharmacological therapy 1
  • Alternative left ventricular assist devices may be considered in patients with refractory cardiogenic shock 1

Follow-up Care

• Left ventricular ejection fraction should be measured in all patients 1
• Patients with initially reduced LV ejection fraction who are candidates for implantable cardioverter-defibrillator therapy should undergo reevaluation of LV ejection fraction 40 or more days after discharge 1
• Exercise-based cardiac rehabilitation programs are recommended for recovery 1

Recent Research

• A pilot study has shown that colchicine may have additional benefits in reducing infarct size in STEMI patients, suggesting its potential value in myocarditis treatment 5
• Recent reviews indicate that approximately 75% of patients with myocarditis have an uncomplicated course, but those with acute heart failure or ventricular arrhythmias have higher mortality rates 2

Special Considerations

• Immunosuppression with corticosteroids may be appropriate for specific forms of myocarditis characterized by eosinophilic or giant cell myocardial infiltrations or due to systemic autoimmune disorders, but not for typical viral myocarditis 2
• Patients presenting with ST elevation should undergo prompt evaluation to differentiate between myocarditis and true myocardial infarction, as treatment approaches differ 3, 4