Complete heart block in late presentation of inferior STEMI successfully treated with percutaneous coronary
Michael Liang1, John Chin, Sanjeevan Pasupati
1Department of Cardiology, Waikato Hospital, Hamilton, Pembroke & Selwyn Sts., Hamilton 3240, New Zealand.
Insights
Late presentation ST elevation myocardial infarction (STEMI) with heart block can be treated with coronary intervention to avoid permanent pacemakers. This case suggests late intervention is a viable strategy for stable patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Electrophysiology
Background:
- Guidelines recommend medical management for late-presenting ST elevation myocardial infarction (STEMI) >72 hours.
- Reperfusion is advised for acute STEMI with atrioventricular block (AVB).
- A clear strategy for late STEMI with advanced AVB is lacking.
Observation:
- A 55-year-old female presented with late STEMI and developed complete heart block.
- She remained hemodynamically stable and underwent temporary pacing wire insertion.
- Coronary angiography revealed an occluded right coronary artery.
Findings:
- Successful percutaneous coronary intervention of the occluded artery was performed.
- The patient's heart rhythm spontaneously reverted to sinus rhythm with first-degree AVB within 24 hours.
- Permanent pacemaker implantation was avoided.
Implications:
- Late coronary intervention may be a beneficial strategy for hemodynamically stable patients with late STEMI and advanced AVB.
- This approach could help patients avoid permanent pacemaker dependency.
- Further research is warranted to establish guidelines for this specific patient population.
Abstract:
A 55-year-old female presented with 4-day history of fatigue and exertional shortness of breath. A late presentation inferior ST elevation myocardial infarction (STEMI) was diagnosed based on ST elevation in the inferior leads of electrocardiography and elevated cardiac troponin T (TnT). She developed complete heart block 1 day after admission to the hospital and remained hemodynamically stable. She was taken to the catheterization laboratory for a temporary pacing wire insertion. Coronary angiogram at the same time showed an occluded right coronary artery at the mid-section. The lesion was successfully opened. Within 24 hours, the patient's heart rhythm returned to sinus with first-degree atrioventricular block (AVB), thus avoiding the need for a permanent pacemaker. Current guidelines recommend medical management for late presentation hemodynamically stable STEMI of more than 72 H onset. Current ACC/AHA/HRS Pacemaker Guidelines recommend reperfusion strategy for acute presentation inferior STEMI associated with AVB. However, no clear strategy exists in the case of late presentation inferior STEMI with advanced AVB. Our case report suggests that late coronary intervention could be a management strategy in such a scenario in order to avoid a permanent pacemaker.
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