Inferior ST-elevation myocardial infarction managed with a pharmacoinvasive strategy and conservative management of
Thadathilankal-Jess John1, Charles Kyriakakis2, Don Zachariah3
1Division of Cardiology, Department of Medicine, Stellenbosch University, Tygerberg Academic Hospital, PO Box 241, Cape Town 8000, South Africa.
Insights
Transient atrioventricular block is a common complication of ST-elevation myocardial infarction (STEMI). Conservative management with temporary pacing can successfully resolve complete heart block following a pharmacoinvasive reperfusion strategy.
Area of Science:
- Cardiology
- Internal Medicine
Background:
- The 2017 European Society of Cardiology (ESC) guidelines offer management strategies for ST-segment elevation myocardial infarction (STEMI).
- Transient atrioventricular (AV) block is a frequent complication of inferior STEMI, with specific management recommendations in the guidelines.
Purpose of the Study:
- To illustrate key management principles for STEMI patients, focusing on the timing and treatment of AV block.
- To emphasize the utility of a pharmacoinvasive strategy for reperfusion when primary percutaneous coronary intervention is delayed.
- To highlight the applicability of this strategy in the context of the COVID-19 pandemic.
Main Methods:
- A case report of a 64-year-old male with cardiovascular risk factors presenting with inferior STEMI and chest pain.
- Initial management included thrombolytic therapy as part of a pharmacoinvasive strategy.
- Emergency angiography revealed critical right coronary artery disease, treated with stenting, followed by the development of complete AV block.
Main Results:
- The patient developed complete AV block after successful stenting, without evidence of re-infarction.
- Conservative management, including temporary transvenous pacing, led to the resolution of the AV block within 7 days.
- The case demonstrates successful application of guideline-directed care for STEMI and its complications.
Conclusions:
- Adherence to ESC guidelines for STEMI management is crucial, particularly regarding AV block.
- A pharmacoinvasive strategy is a viable reperfusion option when timely primary percutaneous coronary intervention is not feasible.
- This approach remains relevant and effective, even in challenging healthcare environments like the COVID-19 era.
Background:
The 2017 ESC guideline on patients with ST-segment elevation myocardial infarction (STEMI) provides guidance regarding the optimal management of these patients. Transient atrioventricular (AV) block is a relatively common complication of inferior STEMI and its management is also addressed in the guidelines.
Case Summary:
A 64-year-old gentleman with multiple cardiovascular risk factors presented to the emergency department with a history of ischaemic type chest pain and evidence of inferior ST-segment elevation on his electrocardiogram (ECG). First-degree AV block was noted on his initial ECG. He was given thrombolytic therapy as part of a pharmacoinvasive strategy of reperfusion. He, however, failed fibrinolytic therapy, and emergency angiography revealed critical disease of the right coronary artery which was successfully stented. Subsequent to reperfusion, he developed complete AV block without evidence of re-infarction, which was managed conservatively with successful resolution of the block after 7 days of expectant management with temporary transvenous pacing.
Discussion:
We highlight some of the important management principles from the ESC guideline of STEMI including timing and the management of AV block in these patients. In addition, we highlight the role of a pharmacoinvasive strategy for reperfusion where timeous primary percutaneous coronary intervention cannot be performed. The usefulness of such a strategy within the COVID-19 era is also emphasized.
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