p.51 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 April 1, 2025 e821

with conservative therapy. Acetaminophen can be given for symptomatic relief. A second form of pericarditis may occur weeks after MI (Dressler’s syndrome) and is believed to be immune-mediated as a response to pericardial irritation or damage, such as in the setting of any degree of hemopericardium.1,2 These cases of late pericarditis often require additional therapy (Table 19). Given the rarity of post-MI pericarditis (0.1%-0.5%) in the era of early coronary reperfusion therapy,3 dedicated RCTs of high-dose aspirin are lacking, and data are extrapolated from studies of the heterogeneous diagnosis of acute pericarditis.4 Furthermore, RCTs of colchicine were performed on a background of high-dose aspirin therapy.5–7 If symptoms persist despite standard supportive therapy in early pericarditis and in any late pericarditis, high-dose aspirin may be used to reduce symptoms.4 The use of colchicine should also be considered to reduce symptoms and decrease risk of recurrence8,9; suggested dosing is summarized in Table 19. The value of a loading dose of colchicine in this setting is unclear. Routine use of high-dose aspirin or colchicine is not indicated for the management of asymptomatic pericardial effusions.10,11 Glucocorticoids and nonsteroidal anti-inflammatory drugs (other than aspirin) are potentially harmful due to possible increase in risk of recurrent MI or impaired myocardial healing and risk of rupture.12,13

9.4 Management of LV Thrombus After MI

Synopsis LV thrombus typically occurs in the setting of large anterior STEMI and can lead to thromboembolic complications, including stroke and systemic embolization. In the era of PCI, the incidence of LV thrombus after ACS has decreased and is estimated to be <5% to 10% in the post-MI population.1–3 Limited RCT data are available on the contemporary management of LV thrombus, and current management is based mostly on retrospective and observational data and expert consensus. Patients at highest risk for LV thrombus include those with anterior STEMI involving the left anterior descending artery, LVEF <30% (especially in the presence of an LV aneurysm), and longer times to reperfusion. An echocardiogram is the recommended imaging modality for diagnosis, given its wide accessibility and low cost.4 Cardiac MRI is more sensitive for detection of LV thrombus and may be considered when there is high clinical suspicion and echocardiogram results are inconclusive. LV thrombus may form later during hospitalization or after discharge; therefore, repeat imaging can sometimes detect LV thrombus in high-risk patients.5 Because DAPT is recommended for most patients early after ACS, the addition of an anticoagulant for LV thrombus needs to be considered in the context of the patient’s overall bleeding risk versus their risk of an embolic event. Most patients with LV thrombus will warrant anticoagulation for a period of 3 months, at which time the presence of residual thrombus can be assessed by repeat imaging to help determine whether a more prolonged course is warranted.1 Although direct oral anticoagulants (DOAC) are routinely used in clinical practice, there are limited data comparing the efficacy of a DOAC versus vitamin K antagonist in the setting of LV thrombus. Observational studies and small RCTs have suggested that DOAC may be noninferior to vitamin K antagonist with respect to mortality, stroke, or LV thrombus resolution, and DOACs may offer an improved bleeding profile.6 The practical management of LV thrombi is more completely addressed in other documents.1,6

10 IN-HOSPITAL ISSUES IN THE

MANAGEMENT OF ACS

10.1 Cardiac Intensive Care Unit

Recommendation for CICU

COR LOE Recommendation

1 C-EO 1 Patients with ACS and with ongoing angina, hemo-

dynamic instability, uncontrolled arrhythmias, suboptimal reperfusion, or cardiogenic shock should be admitted to a CICU to reduce cardiovascular events.

Synopsis The nurse-to-patient ratio in the CICU should be sufficient to provide (1) continuous electrocardiographic rhythm monitoring, (2) frequent assessment of vital signs and mental status, and (3) ability to perform rapid cardioversion and defibrillation for arrhythmias.1,2 Some hospitals may not have a dedicated CICU but rather care for patients with MI within a general multipurpose ICU; this approach requires trained providers with sufficient expertise in the care of cardiac patients.

Table 18.  Clinical Criteria for Diagnosis of Pericarditis Diagnosis Is Made With Presence of Pleuritic Chest Pain and ≥1 of the Following Criteria: Friction pericardial rub on auscultation Electrocardiographic evidence such as classic PR-segment depression or diffusive concave ST-segment elevations, or in the setting of MI, persistent ST-segment elevations or dynamic T-wave changes New or growing pericardial effusion on echocardiography MI indicates myocardial infarction.

Table 19.  Additional Therapy for Persistent/Late Pericarditis Symptoms Medical Therapy Dosing Schedule High-dose aspirin 500-1000 mg every 6-8 h until symptoms improve Colchicine 0.5-0.6 mg once* or twice daily for 3 mo *Daily dosing should be used in patients who weigh <70 kg and further adjusted in patients with stage 4-5 kidney disease, severe hepatic impairment, or with concomitant P-glycoprotein and/or moderate and severe CYP3A4 inhibitors.

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