Friday, January 11, 2019

The Interventionalist Refuses Angiography, and even to speak to the Emergency Physician

A recent residency graduate, let's call her "The Graduate" or "TG," texted me these ECGs from somewhere far away across the country, in real time, in the hopes of being able to persuade the interventionalist to take the patient to the cath lab.

Case

An otherwise healthy middle-aged patient presented with chest pain of uncertain duration.

Here is the initial ED ECG (I apologize for the poor quality of these images -- they were mobile phone photos of computer screens, texted to me -- but they are good enough!):
What do you see?
There was a second ECG after the patient had symptom resolution:
What do you see?
















This is what TG and I saw: ST elevation in lead V1 during pain (with a tiny amount of terminal T-wave inversion), then resolution of STE and more prominent T-wave inversion after resolution of pain (ECG 2).  Looks like Wellens' in V1 only!  This ECG is typical of the rare isolated right ventricular STEMI.

There is also some very minimal inferior STE, with reciprocal STD in aVL, which is gone after reperfusion (ECG 2).  The very narrow-based, peaked T-waves would be an unusual manifestation of MI.

There is quite a bit of diffuse T-wave peaking.  Hyperkalemia can result in ST elevation in V1 and V2, so one might wonder about hyperkalemia, although such ECGs really look very different from this, especially because the QRS should be prolonged.  In our case here, the K was normal.

Here are examples of ST elevation in V1 due to hyperkalemia.


Hyperkalemia and ST Segment Elevation, Post 1




Case Continued

At this point, the first troponin I returned at 1.1 ng/mL.  The potassium was normal.

The pain returned and a 3rd ECG was recorded:
STE in V1 recurs.  Again, there is some minimal inferior STE, with reciprocal STD in aVL.  Very suspicious for inferior and RV OMI (Occlusion MI)
The very narrow-based, peaked T-waves are an unusual manifestation of MI.

This is the point at which TG texted me.

The interventionalist did not want to take the patient to the cath lab.  Antiplatelet and antithrombotic therapy had already been initiated.

TG wrote: "By being persistent, I'm not making friends with cardiology.  They are refusing cath.  They say to treat the MI medically only."

I wrote: "Tell him that by the recommendations of the American College of Cardiology and the American Heart Association, a patient with persistent symptoms in spite of medical treatment who is having acute coronary syndrome should go emergently to the Cath Lab. This is by the recommendations of their own societies.  ACC/AHA Guidelines for the management of Non ST Segment Elevation  Myocardial Infarction. And this is regardless of the ECG findings."

"Moreover, in this case you have ST Elevation in V1.  This is an RV infarct."

I continued:

"The European society of Cardiology recommends emergent and angiography for patients even with normal biomarkers if you believe they are having acute coronary syndrome with refractory symptoms."

"All studies randomizing patients to early versus delayed catheterization exclude patients with refractory symptoms, and this patient has refractory symptoms."

"This is because people can have a major coronary occlusion and no EKG findings."

"And this one has EKG findings!"

TG responded:  "So far he is refusing to talk with me and only wants my name and refusing to give recommendations."  

I replied: "Is there any code of conduct in your hospital? It's hard to believe that he can refuse to talk to you."

She replied: "I don't know - I'm new here.  Thanks for the backup!"

Smith: "Any time. Sorry can't fix personality problems!"

Would an emergent echocardiogram have helped?  Not necessarily.  The cardiologist recognized it was an MI but only wanted medical therapy; he/she probably would have expected a wall motion abnormality.

She: "Update: new interventional is just came on and will take to cath lab. Still in pain.  Here is a 4th EKG:"
Now there is an obvious inferior STEMI, with persistent right ventricular MI.  The ST segment in V2 shows posterior involvement as well.
The patient was taken to the cath lab and found to have an acute proximal RCA occlusion.


Learning Points:

1. See all of the above.
2. Hospitals should consider adopting a Code of Conduct.

Code 1: One of the elements would be that a consultant must at least speak to any physician asking for help in caring for a patient.

Code 2:  When there is disagreement on critical next steps in emergency patients, there needs to be some mechanism to rapidly resolve the disagreement.


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Comment by KEN GRAUER, MD (1/11/2019):
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I don’t have much to add to the excellent discussion by Dr. Smith of this case:
  • Perhaps right-sided leads could have helped to convince the 1st interventionalist that this case merited prompt cardiac catheterization with reperfusion therapy? Given the dramatic amount of ST elevation in lead V1 — it would seem that there almost certainly would have been extensive ST elevation in sequential right-sided leads, that would have painted an even more impressive picture. Then again, given resistance by this initial interventionalist to even talk to the treating physician — nothing might have been “enough” to convince him of the need for prompt cardiac cath ... (P.S.: It should be emphasized that in this case — right-sided leads are not needed to make the diagnosis of acute RV MI, because V1 alone is sufficient. I'm simply suggesting that a dramatic right-sided lead picture might help to convince a skeptical cardiologist ... ).
  • As per Dr. Smith — the finding of tall, peaked T waves with narrow base in multiple leads (8/12 leads on the 1st ECG) is an unusual manifestation of acute MI. Serum K+ was normal — confirming that these tall, narrow T waves were indeed a “hyperacute” finding. I’ve not before seen T waves so prominent and pointed with such a narrow base in so many leads, in association with a normal serum K+ in a patient with acute OMI. Though not common — this is a picture worth remembering!
  • Final Thought: It is not easy when you are the clinician “on the front line” — and your consultant cardiologist, surgeon, or other specialty physician that you have consulted refuses to engage in active dialog with you about your patient. Fortunately, a 2nd interventional cardiologist took over this case. Otherwise: iCalling someone else, regardless of the hour (either medical chief of staff or another consultant) may be your only option; andiiDevelopment of a protocol for rapid resolution of such clinical impasses needs to take 1st priority at the very next medical staff meeting.
  • Important lessons to be learned in this case! Our thanks to Dr. Smith for presenting it!


10 comments:

  1. Hi Dr. Smith,

    Frustrating case for sure!! Concerning the initially ECG, with the minimal STE in the inferior and the TWI/STD in the high laterals would this not support a inferior MI with infarct? Also, how would you feel about TNKase in this scenario to chemically reprefuse the OMI?

    ReplyDelete
    Replies
    1. Yes, it would. But even if you don't see the ECG changes, you know by troponin and persistent symptoms that the patient MUST go emergently to cath lab.

      Delete
  2. I find it interesting that telephonically and without seeing the patient the cardiologist refused to see the case. In our institution we have a rule that even if you disagree with ER referral you are obliged to go see patient in person, apply yourself clinically and then refer the patient to am elsewhere dept if you disagree with the ER referral. But you can not override an assessment without having made your own assessment in person. Not over the phone.

    ReplyDelete
    Replies
    1. Your system is the way it should be!

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    2. Refusing patients over the phone without seeing them is pretty much how our cardiology department is working at our hospital, but we have the problem of working in Sweden with an immature emergency medicine system. Most hospitals pretty much are stuck in the situation you were in around 1970 when you let junior doctors handle the emergent patients with little supervision. Hence a lot of consultants are used to being able to tell the ER what to do. Let's just say that we are going to have a culture clash when more and more ER:s are staffed by actual emergency medicine specialists...

      Certainly can agree on it being mandatory to see a patient yourself if there is disagreement. A lot easier to recomend some things and let someoneelse handle the consequences.

      Delete
    3. Johan,
      Thanks. Don't let them discourage you!
      Steve

      Delete
  3. Could they have done a 15lead V4R, V8, V9 and confirm R sided MI and possible Posterior infarct?

    ReplyDelete
    Replies
    1. That probably would have provided more evidence, but shouldn't have been necessary!

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  4. Great case. As another "The Graduate" of Dr Smith's mentoring, this is the dedicated and passionate care he always demonstrates for patients...even many miles away. Thank you for your dedication for the continuous education OMI.

    ReplyDelete

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