I received a question yesterday: "If spontaneous reperfusion (or aspirin/nitro assisted reperfusion) occurs, why is it so important to rush for reperfusion therapy?" This is a very good question. To my knowledge, there is no randomized trial of immediate PCI vs. delayed PCI for transient STEMI. There is a study that randomized patients with NSTEMI to early vs. delayed PCI. It showed that patients at high risk, as measured by a GRACE score of 140 or greater (corresponding to an in-hospital mortality of 3%), had better outcomes if they underwent immediate angiogram and PCI.
[Mehta SR et al. NEJM May 21, 2009; 360(21):2165.]
I do let the following anecdote affect my practice:
This was a 52 year-old male I saw a few years back. He was playing cards with his friends when his left hand became numb. He had no CP or SOB, no arm or jaw or other pain. His friends thought he was having a stroke and called 911. The medics wisely recorded the following ECG prehospital.
He arrived in the ED still without any chest pain, and the medics showed me this ECG:
|There is marked ST elevation in anterior precordial leads, and reciprocal ST depression in inferior leads. This is diagnostic of proximal LAD occlusion.|
I activated the cath lab at 2129 in spite of the fact that the patient was asymptomatic.
We then recorded this ECG:
|There is some ST depression in V2 and V3 and hyperacute T-waves.|
Hyperacute T-waves can occur "on the way up" or "on the way down" as I like to say; this means they can be present shortly after occlusion before ST elevation, or shortly after reperfusion, after ST segments have resolved. I considered this to be diagnostic of reperfusion.
So I de-activated the cath lab at 2135.
Then the patient became hypotensive. We recorded this ECG:
|Obvious anterior STEMI|
Shortly after the LAD angiogram, which showed 100% occlusion, the patient arrested and could not be resuscitated.
If I had let the cath lab be activated in spite of reperfusion, he would be alive.
This was a big mistake of mine.
Any STEMI is very high risk, even if reperfused. I don't believe you'll ever be criticized for activating the cath lab if you have just one ECG that is diagnostic of STEMI.