What is the role of systemic steroids in the management of ST-Elevation Myocardial Infarction (STEMI) versus Non-ST-Elevation Myocardial Infarction (NSTEMI)?

Systemic Steroids Have No Role in STEMI or NSTEMI Management

Systemic corticosteroids should not be used in either STEMI or NSTEMI, as they are potentially harmful and contraindicated for post-infarction complications like pericarditis. 1

Why Steroids Are Contraindicated

In STEMI Patients

• Glucocorticoids are explicitly contraindicated for treatment of post-STEMI pericarditis due to potential harm, as stated by the American College of Cardiology and Circulation guidelines. 1
• The mechanism of harm relates to impaired myocardial healing and increased risk of ventricular rupture, though the guidelines do not elaborate on specific mechanisms. 1

In NSTEMI Patients

• No guideline recommendations exist supporting systemic steroid use in NSTEMI management. 2
• The comprehensive ACC/AHA NSTEMI guidelines from 2007 and 2013 make no mention of corticosteroids as part of the therapeutic armamentarium. 2

Recommended Pain Management Instead

For STEMI

• Morphine sulfate (2-4 mg IV with increments of 2-8 mg repeated at 5-15 minute intervals) is the analgesic of choice, particularly in patients with acute pulmonary edema. 2, 1
• Acetaminophen 500 mg orally every 6 hours can be added if additional pain control is needed. 1
• Colchicine 0.6 mg every 12 hours orally may be added for pericarditis not adequately controlled with aspirin alone. 1

For NSTEMI

• Morphine sulfate IV is reasonable for uncontrolled ischemic chest discomfort despite nitroglycerin, though it should be used with caution as retrospective data suggest potential adverse effects in UA/NSTEMI patients. 2
• Nitroglycerin 0.4 mg sublingual every 5 minutes for up to 3 doses, followed by IV nitroglycerin for persistent ischemia. 2, 3

Anti-Inflammatory Considerations

What NOT to Use

• NSAIDs (both non-selective and COX-2 selective) are Class III contraindications in both STEMI and NSTEMI due to increased risks of mortality, reinfarction, hypertension, heart failure, and myocardial rupture. 2, 1, 3
• This prohibition applies during hospitalization and should continue after discharge. 2, 1

What TO Use

• Aspirin remains the cornerstone anti-inflammatory and antiplatelet therapy and must be continued in all patients without contraindications. 2, 4, 3
• Aspirin dosing: 162-325 mg initially (non-enteric formulation, chewed), then 75-162 mg daily long-term. 2

Important Clinical Pitfall

Do not confuse local corticosteroid injections (intra-articular, epidural, soft tissue) with systemic corticosteroids. 4 Local injections are not mentioned as contraindicated in cardiac guidelines and have different risk profiles than systemic administration. 4 However, this distinction is irrelevant to the management of acute MI itself, where systemic steroids have no therapeutic role.

Standard Evidence-Based Management

Both STEMI and NSTEMI Require:

• Beta-blockers within 24 hours (oral route) in patients without signs of heart failure, low-output state, or increased cardiogenic shock risk. 2, 3
• ACE inhibitors within 24 hours for patients with pulmonary congestion, LVEF ≤0.40, or anterior STEMI, provided systolic BP >100 mmHg. 2, 1, 3
• Antiplatelet therapy with aspirin plus a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor). 2
• Anticoagulation with unfractionated heparin, low molecular weight heparin, or fondaparinux. 3

The evidence is unequivocal: systemic steroids have no therapeutic role in acute MI management and are explicitly harmful when used for post-infarction complications.