What is the initial treatment for a patient presenting with pericarditis and ST elevations?

Initial Treatment for Pericarditis with ST Elevations

Aspirin is the recommended first-line treatment for patients presenting with pericarditis and ST elevations. 1

First-Line Treatment

• Aspirin is the primary anti-inflammatory treatment for pericarditis after STEMI, with a Class I recommendation (Level of Evidence: B) 1
• Aspirin should be administered at doses of 750-1000 mg every 8 hours for 1-2 weeks with gastroprotection 2
• Treatment duration should be guided by symptom resolution and normalization of C-reactive protein (CRP) levels 2
• Tapering should be considered by gradually decreasing doses (e.g., aspirin by 250-500 mg every 1-2 weeks) 2

Second-Line Treatment Options

• Colchicine 0.6 mg every 12 hours orally should be added to aspirin therapy if symptoms are not adequately controlled with aspirin alone (Class IIa recommendation) 1, 3
• Weight-adjusted dosing of colchicine is recommended: 0.5 mg once daily if <70 kg or 0.5 mg twice daily if ≥70 kg 2
• Colchicine should be continued for at least 3 months to reduce the risk of recurrence (reduces recurrence from approximately 30% to 17%) 2, 4
• Acetaminophen 500 mg orally every 6 hours may be added if pain control remains inadequate (Class IIa recommendation) 1, 3

Medications to Avoid

• Glucocorticoids and nonsteroidal anti-inflammatory drugs (NSAIDs) other than aspirin are potentially harmful for treatment of pericarditis after STEMI (Class III: Harm recommendation) 1, 3
• These medications are associated with increased risk of myocardial scar thinning, infarct expansion, and promotion of chronicity 1, 2
• If NSAIDs must be used, they should not be used for extended periods due to their continuous effect on platelet function 1

Diagnostic Considerations

• Pericarditis should be considered in the differential diagnosis of recurrent chest pain after STEMI, particularly when the discomfort is pleuritic or positional, radiates to the trapezius ridge, and is associated with a pericardial friction rub 1
• Recurrent or worsening ST elevation without early T-wave inversion may be present in pericarditis 1
• It is crucial to distinguish pericarditis from reinfarction or acute stent thrombosis 1

Management of Complications

• Cardiac imaging with echocardiography should be performed to assess ventricular function and detect complications 3
• It is important to exclude rupture when a pericardial effusion is present, especially if the width of the effusion is >1 cm 1
• Anticoagulation should be discontinued in the presence of a significant (≥1 cm) or enlarging pericardial effusion due to risk of hemorrhagic conversion 1
• Exercise restriction should be considered until symptoms resolve and CRP, ECG, and echocardiogram normalize 2

Treatment Algorithm

1. Start with aspirin 750-1000 mg every 8 hours 2
2. Add colchicine 0.6 mg every 12 hours if symptoms persist 1, 3
3. Add acetaminophen 500 mg every 6 hours if pain control is inadequate 1, 3
4. Consider narcotic analgesics only if pain remains uncontrolled despite the above measures 1, 3
5. Monitor response using CRP to guide treatment length 2
6. Taper medications gradually once symptoms resolve and CRP normalizes 2

Pitfalls and Caveats

• Inadequate treatment of the first episode is a common cause of recurrence 2
• The incidence of acute pericarditis after STEMI has decreased with aggressive use of reperfusion therapy 1
• Although pericarditis is not an absolute contraindication to anticoagulation, caution should be exercised because of the potential for hemorrhagic conversion 1
• Recurrence rates after initial episode range from 15-30% without colchicine, increasing to 50% after first recurrence 2, 4