The AHA Guidelines and Scientifi c Statements Handbook
(2 mg) doses of atropine have been used, transcuta-
neous or transvenous (preferably atrial) temporary
pacing should be instituted. (Level of Evidence: C)
Pacing mode selection in STEMI patients
Class I
All patients who have an indication for permanent
pacing after STEMI should be evaluated for ICD
indications. (Level of Evidence: C)
Class IIa
1 It is reasonable to implant a permanent dual-
chamber pacing system in STEMI patients who need
permanent pacing and are in sinus rhythm. It is
reasonable that patients in permanent atrial fi brilla-
tion or fl utter receive a single chamber ventricular
device. (Level of Evidence: C)
2 It is reasonable to evaluate all patients who have
an indication for permanent pacing after STEMI for
biventricular pacing (cardiac resynchronization
therapy). (Level of Evidence: C)
G. Recurrent chest pain after STEMI
See Figure 3.7.
- Pericarditis
Class I
1 Aspirin is recommended for treatment of pericar-
ditis after STEMI. Doses as high as 650 mg orally
(enteric) every 4 to 6 hours may be needed. (Level
of Evidence: B)
2 Anticoagulation should be immediately discon-
tinued if pericardial effusion develops or increases.
(Level of Evidence: C)
Class IIa
For episodes of pericarditis after STEMI that are not
adequately controlled with aspirin, it is reasonable
to administer one or more of the following:
a. Colchicine 0.6 mg every 12 hours orally. (Level
of Evidence: B)
b. Acetaminophen 500 mg orally every 6 hours.
(Level of Evidence: C)Class IIb
1 Nonsteroidal anti-infl ammatory drugs may be
considered for pain relief; however, they should not
be used for extended periods because of their con-
tinuous effect on platelet function, an increased risk
of myocardial scar thinning, and infarct expansion.
(Level of Evidence: B) [17]
2 Corticosteroids might be considered only as a last
resort in patients with pericarditis refractory to
aspirin or nonsteroidal drugs. Although corticoste-
roids are effective for pain relief, their use is
associated with an increased risk of scar thinning
and myocardial rupture. (Level of Evidence:
C)Class III
Ibuprofen should not be used for pain relief because
it blocks the antiplatelet effect of aspirin and can
cause myocardial scar thinning and infarct expan-
sion. (Level of Evidence: B)- Recurrent ischemia/infarction
Class I
1 Patients with recurrent ischemic-type chest dis-
comfort after initial reperfusion therapy for STEMI
should undergo escalation of medical therapy with
nitrates and beta-blockers to decrease myocardial
oxygen demand and reduce ischemia. Intravenous
anticoagulation should be initiated if not already
accomplished. (Level of Evidence: B)
2 In addition to escalation of medical therapy,
patients with recurrent ischemic-type chest discom-
fort and signs of hemodynamic instability, poor LV
function, or a large area of myocardium at risk
should be referred urgently for cardiac catheteriza-
tion and undergo revascularization as needed. Inser-
tion of an IABP should also be considered. (Level of
Evidence: C)
3 Patients with recurrent ischemic-type chest dis-
comfort who are considered candidates for revascu-
larization should undergo coronary arteriography
and PCI or CABG as dictated by coronary anatomy.
(Level of Evidence: B)
Class IIa
It is reasonable to (re)administer fi brinolytic therapy
to patients with recurrent ST elevation and isch-
emic-type chest discomfort who are not considered
candidates for revascularization or for whom coro-
nary angiography and PCI cannot be rapidly (ideally
within 60 minutes from the onset of recurrent
discomfort) implemented. (Level of Evidence:
C)