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Thursday, July 12, 2012

STEMI with a twist... and then a second twist!

This would make a lousy case for a EMS 12-Lead-style presentation, because it's a little to difficult to predict the outcome. And I can't really find a new EMS study, or even an old one, to present with this. If there is any lesson to learn from this case, it would have to be: patients will keep you humble.

The Patient
The history was a little iffy, as the patient was elderly and had a history of both CVAs and dementia, and was variably describing either a week of chest pain or "Nothing! I'm fine!"

EMS had called with a STEMI, though, so I met the paramedics at the ED door, and they handed me the ECG:



You know, they say "treat the patient, not the monitor," but when this shows up on the monitor, you treat that.

We grabbed another ECG after cards had been called for the cath lab activation:


By the way,  I know some sharp readers out there are already asking for right-sided leads, but V4R didn't reveal too much. But even without that, one could make a stab at guessing the infarct-related artery - it seems sort of classic. The STE in III versus aVF, the depressions in aVL and I, not to mention V2, all pointed to an RCA lesion. Intern stuff.

And then the cards fellow asks me if I've seen the patients old ECG. Oh, give me a break...



Twist #1
Now, I almost always check the old ECGs before I call cards, but in this case I was wondering how the old ECG could possibly be relevant to this clearly acute ischemia...

Ah. I see.
This ECG was recorded a number of months prior. The patient, at that time, had been brought to the hospital for another medical emergency, and was incidentally found to have an apparent STEMI. The catheterization revealed a totally occluded RCA, likely chronic.

"What a twist!"

Sooo, no cath then?

Despite the vague history the patient provided, it seemed consistent enough with AMI. There was also some concern that the collaterals that were serving her right ventricle might have acutely occluded.On top of all that, the deep drop in her blood pressure (thankfully transient) after I gave her nitroglycerin seemed to confirm the ECG. Off to the cath lab she went, leaving me feeling only somewhat less sheepish.

Twist #2
And the infarct related artery was...

"Ta-da!"


The LAD.

A "hazy appearing" lesion was visualized fairly proximally in the LAD, just before the first diagonal. Just to be sure, they used the intravascular ultrasound to confirm the freshly-ulcerated plaque, and put in a few stents. All better!

Follow-up
Well, not really. Our patient suffers from "multiple comorbidities," and did not tolerate the procedure so well. A ballon-pump was placed to support her hypotension during the procedure, and during her subsequent hospital stay any number of issues have popped up; bleeding, sepsis, renal stuff.

And her current ECG, a month later?


Huh.

Bottom line
Stay humble. I like to think that I've gotten pretty good at guessing the culprit artery in STEMI, but I was out of my depth on this one!

7 comments:

  1. Wow. Just wow. That's when your crews ask the patient to keep their old ECG on their person...taped to their forehead.

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  2. Fantastic. I like to have one totally blindside me every so often as a reminder that name-the-artery is an inexact science, particularly in those with extensive chronic stenosis who are heavily collateral-dependent. (It's like trying to figure out why an accident at one end of the city is jamming up traffic twelve blocks away on an unrelated street... it's all connected.)

    100% RCA occlusion, though? Is that often seen as a chronic, stable finding?

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    1. Chronic occlusions are walking around us every day, but the ECGs are nothing special.

      You can see reciprocal depressions in LV aneurysm, but no aneurysm was noted on either of the catheterizations. I read Dr. Smith's rule for determining LAD STEMI versus old LV aneurysm (http://www.ncbi.nlm.nih.gov/pubmed/15915398), but I'm not sure how well it translates to the RCA.

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    2. I suppose it's just that most of the longstanding occlusions I've seen are usually non-total. Good collaterals or no, you'd have trouble convincing me that zero flow through one of the big three might be no big deal.

      I like Dr. Smith's rule. It's perhaps less validated for the RCA but I don't see why the principles wouldn't hold true. (My general attitude is that "LVA" on the ECG doesn't necessarily denote an actual aneurysm, it's just what the heart does in the aftermath. I suppose the actual presence of a true aneurysm could be clinically relevant, but diagnosing/managing it is well beyond my ken...)

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  3. So its an interior MI the whole time.... where's the twist?

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    Replies
    1. Sorry if my writing isn't so clear - too much coffee while revising!

      I had thought that this would be a classic right coronary artery occlusion (which would be an INFerior MI), but the old ECG (twist #1) made me think that it was actually an old left ventricular aneurysm - no acute MI involved.

      When the cardiologist found a fresh-appearing lesion in the left anterior descending artery (an ANTerior MI), that was twist #2, since an LAD STEMI typically has an ECG that looks nothing like what I was looking at.

      Even with hindsight, it's difficult to find ECG evidence of LAD occlusion.

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  4. AHHHHHH.... thank you for the clarification.

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