Published: January 12th, 2016

Category: STEMI

Pre-hospital ECG:


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
  • Mechanism
    • 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).
  • Causes
    • 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



Inferior MI

  • 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