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Introduction The use of contemporary drug-eluting stents (DES) has significantly improved outcomes of patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). Patients with left main (LM) disease, cardiogenicshock (CS), or severely reduced left-ventricular ejection fraction (LVEF) were excluded.
Now appears to be in cardiogenicshock." This is ischemia until proven otherwise. However, cardiogenicshock usually takes some time to develop, so it is probably subacute." Cardiogenicshock and ACS is an indication for the cath lab, even if you don't think there is OMI. I was texted these ECGs.
A man in his 70s with past medical history of hypertension, dyslipidemia, CAD s/p left circumflex stent 2 years prior presented to the ED with worsening intermittent exertional chest pain relieved by rest. The baseline ECG is basically normal with no ischemia. In my opinion, I think it looks more like subendocardial ischemia.
The patient was referred immediately for cath which revealed RCA occlusion that was stented. Remember, in diffuse subendocardial ischemia with widespread ST-depression there may b e ST-E in lead s aVR and V1. There are well formed R-waves with good voltage/amplitude which is uncommon for ischemia. There is ST depression in V1.
Similarly, STEMI guidelines call for urgent angiography for refractory ischemia or electrical/hemodynamic instability, regardless of ECG findings. So there is now high pre-test probability + refractory ischemia + Modified Sgarbossa + dynamic ECG changes. So the RCA was stented. Learning points 1.
The patient has also developed sinus bradycardia, which may result from right coronary artery ischemia to the SA node. The patient is started on epinephrine infusion for cardiogenicshock and cardiology took the patient to the cath lab. Two stents were placed with resultant TIMI 3 flow.
So the patient was taken for emergent cath, showing: Culprit artery: LAD (100% stenosis, TIMI 0) requiring thrombectomy and stent. EKG shown here: LAFB with no clear signs of OMI or ischemia. Queen of Hearts interpretation: Now the cardiologist considered it "STEMI"! No labs were performed. EKG and CT head were performed.
distal stent patent. The patient went into cardiogenicshock and ultimately died of this MI. Given our concern about possible subtle high-lateral OMI — this raises the question whether the upright T waves in leads V1 and V2 of this 1st ECG might be abnormal and reflect ischemia. The cath lab was activated.
The axiom of "type 1 (ACS, plaque rupture) STEMIs are not tachycardic unless they are in cardiogenicshock" is not applicable outside of sinus rhythm. In some cases the ischemia can be seen "through" the flutter waves, whereas in other cases the arrhythmia must be terminated before the ischemia can be clearly distinguished.
Post by Smith and Meyers Sam Ghali ( [link] ) just asked me (Smith): "Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR?" That said, complete LM occlusion would be expected to have subepicardial ischemia (STE) in these myocardial territories: STE vector 1.
Why is the patient in shock? He was in profound cardiogenicshock. RCA ischemia often results in sinus bradycardia from vagal reflex or ischemia of the sinus node. He was successfully stented. There is an obvious inferior STEMI, but what else? This STE is diagnostic of Right Ventricular STEMI (RV MI).
He had undergone stenting of the LAD several weeks ago (unclear whether elective for stable symptoms, or in response to acute coronary syndrome). That the chief complaint of today's patient was acute CP ( C hest P ain ) with a history of known coronary disease and LAD stent placement a few weeks earlier. He appeared critically ill.
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