Sunday, March 31, 2013

Prehospital Serial ECGs demonstrate repeated Reperfusion and Reocclusion

A 78 yo male had a syncopal event and complained of chest pain.

Here are 9 prehospital ECGs during transport:

0 minutes, nondiagnostic
4 minutes, inferior STEMI (subtle).
5 minutes, reperfused, barely shows on the ECG
7 minutes, almost normal again.
15 minutes, more obvious


16 minutes, more obvious, NTG given here

22 min, with V4R, STE gone after NTG and Aspirin



23 minutes, very subtle, resolving

29 minutes, almost entirely resolved



The cath lab was activated prehospital and the patient received an RCA stent and an LAD stent, had a minimal troponin rise, and did well.

This shows how acute coronary syndrome is very dynamic, with arteries opening and closing.  Studies using continuous 12-lead monitoring show that this happens even in the abscence of chest pain.

4 comments:

  1. Dr. Smith,

    Would you call a STEMI based on EKG 2? I've always learned stemi is 2mm STE in 2 contiguous leads, or 1mm in 2 contig. leads in the precordial leads? Thanks.

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    Replies
    1. Yes. 1 mm in 2 consecutive leads is not sensitive enough. There are certain patterns which are coronary occlusion even if they do not meet these arbitrary criteria. Much of my blog is devoted to that.

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    2. That was a very good question, by the way. We need to find the "Non-STEMIs" that are coronary occlusions. (30% of NonSTEMIs are found to have an occluded infarct-related artery at next day cath.

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