Emergency Department ECG:
Cardiac Cath Report:
LM– Medium, no angiographic stenosis
LAD– Normal caliber, transapical, LAD has mild diffuse disease, mid LAD has intra myocardial bridging
LCx– Normal caliber, proximal 20% stenosis, gives rise to small to medium OM 1 which has mild disease. Large PLV has no angiographic stenosis
RCA– Normal caliber, dorminant, 95% stenosis with filling defect in proximal stent likely thrombus (in-stent thrombosis), mild instent restenosis distal to filling defect. PDA/PLV are patent
Intervention: Balloon angioplasty to in-stent RCA thrombosis
Complete Heart Block
- Complete absence of AV conduction
- Perfusing rhythm is maintained by a junctional or ventricular escape rhythm
- It may be due to progressive fatigue of AV nodal cells as per Mobitz I (e.g. secondary to increased vagal tone in the acute phase of an inferior MI).
- Alternatively, it may be due to sudden onset of complete conduction failure throughout the His-Purkinje system, as per Mobitz II (e.g. secondary to septal infarction in acute anterior MI).
- Inferior MI
- AV nodal blocking drugs
- Idiopathic degeneration of conduction system
- Complete Heart Block Complicating ST-Segment Elevation Myocardial Infarction : Temporal Trends and Association With In-Hospital Outcomes [JACC 2015;1(6):529-38]
- 2,273,853 patients with STEMI, 49,882 (2.2%) had CHB
- STEMI patients with CHB had higher in-hospital mortality than those without CHB
- The higher mortality associated with CHB was independent of the location of STEMI
- The incidence of CHB was higher in patients with inferior STEMI compared with those with anterior STEMI
- 40-50% of all myocardial infarctions.
- more favorable prognosis than anterior myocardial infarction
- Up to 40% of patients with an inferior STEMI will have a concomitant right ventricular infarction. These patients may develop severe hypotension in response to nitrates and generally have a worse prognosis.
- Confirmed with Right sided ECG, Elevation in V4R
- Up to 20% of patients with inferior STEMI will develop significant bradycardia due to second- or third-degree AV block. These patients have an increased in-hospital mortality (>20%).
- ECG findings
- ST elevation in leads II, III and aVF
- Reciprocal ST depression in aVL (± lead I)
- RCA (80%): Elevation in III > II, Reciprocal depression in I
- LCx (20%): Elevation in III = II, No reciprocal depression in I