Which of the following complications of ST-Elevation Myocardial Infarction (STEMI) has incorrect management: a) Pericarditis treated with Aspirin, b) Mural thromboembolism treated with Rivaroxaban (rivaroxaban) for 3-6 months, c) True Ventricular aneurysm treated with Surgical Repair, or d) Acute Pericarditis without anticoagulation unless compelling indication?

Incorrect Management of STEMI Complications

Option C (True Ventricular aneurysm requiring surgical repair as rupture is highly likely) is the INCORRECT statement. True ventricular aneurysms are actually characterized by a LOW risk of rupture and rarely require surgical intervention based solely on rupture risk.

Analysis of Each Option

Option A: Pericarditis - Aspirin 650mg QID (CORRECT Management)

• High-dose aspirin is the recommended first-line treatment for post-STEMI pericarditis 1
• The European Society of Cardiology specifically recommends high-dose intravenous aspirin (1000 mg/24h) or oral equivalent for troublesome pericardial pain 1
• The ACC/AHA guidelines confirm aspirin as the Class I recommendation for pericarditis after STEMI 1
• NSAIDs and glucocorticoids are potentially harmful and should be avoided in post-STEMI pericarditis 1

Clinical Pitfall: Do not confuse post-STEMI pericarditis with Dressler syndrome (which occurs later and presents with systemic features). Both are treated with aspirin, but the timing and presentation differ 1.

Option B: Mural Thromboembolism - Rivaroxaban 3-6 months (INCORRECT - Wrong Drug Choice)

While the duration of 3-6 months is appropriate, rivaroxaban is NOT the recommended anticoagulant for LV mural thrombi post-STEMI:

• Vitamin K antagonists (warfarin) are the guideline-recommended therapy for intraventricular thrombi, particularly if mobile or protuberant 1
• The ACC/AHA guidelines recommend warfarin (INR 2.0-3.0) for at least 3 months for documented LV thrombus 1
• Initial treatment should be with IV unfractionated heparin or LMWH, followed by oral anticoagulants 1
• The 2013 ACC/AHA guidelines give Class IIa recommendation for vitamin K antagonist therapy in patients with asymptomatic LV mural thrombi 1

Important Note: Rivaroxaban is approved for VTE treatment 2, 3, 4, 5 and extended antithrombotic therapy in stable CAD 1, but NOT specifically for LV mural thrombi post-STEMI. The evidence base for direct oral anticoagulants in this indication is lacking in the guidelines.

Option C: True Ventricular Aneurysm - Surgical Repair (INCORRECT Management)

This is the INCORRECT statement because true ventricular aneurysms have LOW rupture risk and rarely require surgery based on rupture concern alone:

• True ventricular aneurysms are characterized by a fibrous wall containing all three layers of the heart (endocardium, myocardium, epicardium)
• Unlike pseudoaneurysms (false aneurysms), true aneurysms have a very low risk of rupture due to their fibrous, stable wall structure
• Surgical repair is typically reserved for:
  • Refractory heart failure
  • Recurrent ventricular arrhythmias not controlled medically
  • Systemic embolization despite anticoagulation
  • Large aneurysms causing significant hemodynamic compromise

Critical Distinction: This contrasts sharply with pseudoaneurysms (false aneurysms), which have a contained rupture with only pericardium preventing free rupture and carry a HIGH risk of complete rupture requiring urgent surgical intervention.

Option D: Acute Pericarditis - Anticoagulation Not Necessary (CORRECT Management)

• Anticoagulation should be used with extreme caution or avoided in acute pericarditis post-STEMI due to risk of hemorrhagic conversion 1
• The European Society of Cardiology states that "antithrombin therapy must be interrupted unless there is an absolute indication for its continuous use" when hemorrhagic effusion with tamponade occurs 1
• The ACC/AHA guidelines note that anticoagulation should be discontinued in the presence of significant (≥1 cm) or enlarging pericardial effusion 1
• Pericarditis is not an absolute contraindication to anticoagulation, but caution should be exercised because of potential for hemorrhagic conversion 1

Clinical Approach: If anticoagulation is absolutely necessary (e.g., mechanical valve, high-risk atrial fibrillation), it should be continued with close echocardiographic monitoring for effusion development 1.

Summary

The answer is C - the statement about true ventricular aneurysm is incorrect because these lesions have LOW rupture risk and do not routinely require surgical repair to prevent rupture. Option B also contains an error (wrong drug choice), but the fundamental management principle (anticoagulation for 3-6 months) is correct, whereas Option C is fundamentally wrong about the rupture risk and surgical indication.