A 43-year-old Female with Retrosternal Chest Pain
Sarah, a 43-year-old female with a medical history significant for smoking and obesity, presents to the emergency department with sudden onset of severe chest pain that started approximately 30 minutes ago. She describes the pain as a squeezing sensation in the center of her chest. She also reports nausea, diaphoresis, and lightheadedness. Upon arrival, her vital signs are as follows: blood pressure 150/95 mmHg, heart rate 110 bpm, respiratory rate 20 breaths per minute, and oxygen saturation 97% on room air. Physical examination reveals no abnormal findings. Her ECG shows ST-segment elevation in leads V1-V4.
This patient’s ECG show ST-elevation in V1-V4 with reciprocal ST-changes in the inferior limb leads.
Case Study Questions & Answers
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The most likely diagnosis for this patient is anterior ST-elevation myocardial infarction (STEMI).
References:
1) https://litfl.com/anterior-myocardial-infarction-ecg-library/
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ST-segment elevation in leads V1 to V4 suggests involvement of the anterior wall of the heart, indicating an occlusion in the left anterior descending artery (LAD) or its branches.
References:
1) https://litfl.com/acute-coronary-syndromes/
2) https://litfl.com/anterior-myocardial-infarction-ecg-library/
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Initial management of all patients who present with STEMI (and indeed for any patient presenting with Acute Coronary Syndrome) is as per the ACS Protocol set out in the Advanced LIfe Support (ALS) Guidelines:
300mg aspirin
GTN spray/sublingual (unless hypotensive or severe RV infarct suspected)
Supplemental oxygen titrated to appropriate target saturations:
Scale 1 = 94-98% target saturations
Scale 2 = 88-92% target saturations
10mg morphine for pain relief as indicated
10mg metoclopramide if nausea/vomiting as indicated
References:
1) https://lms.resus.org.uk/modules/m15-v2-acute-coronary/11118/resources/chapter_4.pdf
2) https://www.nice.org.uk/guidance/cg95/evidence/full-guideline-245282221
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Primary PCI offers advantages over fibrinolytic therapy, including higher rates of successful reperfusion, lower rates of reinfarction, reduced risk of complications (e.g. cerebral haemorrhage) and reduced overall mortality. PCI also allows for simultaneous coronary angiography, facilitating the identification of additional lesions and the potential for immediate intervention. PCI is the most reliable method of re-opening and maintaining coronary artery patency and there is reduced risk of major bleeding, especially intracerebral haemorrhage, with PCI compared with fibrinolytic therapy. Hospitals should aim to achieve a “call-to-balloon time” of less than 120mins as delays are associated with a higher mortality. If PCI is not immediately available within this timeframe then initial treatment with fibrinolytic therapy should be given and PCI performed later IF possible.
Although fibrinolytic therapy alone is less effective than PCI, it still substantially reduces mortality from MI when given in a timely manner (i.e. first few hours of chest pain onset). The advantage of fibrinolytic therapy is that it does not require a cath lab or a team skilled in angioplasty. In cases where PCI is not possible (no team available, nearest centre too far etc.) then early reperfusion may be achieved with fibrinolytic therapy instead.
References:
1) https://lms.resus.org.uk/modules/m15-v2-acute-coronary/11118/resources/chapter_4.pdf
2) https://www.nice.org.uk/guidance/cg95/evidence/full-guideline-245282221
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Factors to consider when deciding between primary PCI and fibrinolytic therapy include the time from symptom onset, the availability of a skilled interventional cardiology team, the distance to a PCI-capable hospital, and the patient's overall clinical stability.
References:
1) https://lms.resus.org.uk/modules/m15-v2-acute-coronary/11118/resources/chapter_4.pdf
2) https://www.nice.org.uk/guidance/cg95/evidence/full-guideline-245282221
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Cardiac biomarkers, specifically troponin levels, play a crucial role in the diagnosis and management of acute coronary syndrome. Elevated troponin levels confirm myocardial injury and allows for differentiation between angina and infarction:
Stable Angina = normal troponin; non-specific ECG changes
Unstable Angina = normal troponin; ECG shows ST-depression or T-wave inversions
NSTEMI = elevated troponin; ECG shows ST-depression of T-wave inversion
STEMI = elevated troponin; ECG shows ST-elevation OR new LBBB OR de Winter T-Waves:
LBBB & de Winter T-waves are considered STEMI equivalents
The troponin can also be used to calculate the patient’s HEART score which predicts their 6-week risk of suffering a major adverse cardiac event. This will help to guide initial management.
References:
1) https://lms.resus.org.uk/modules/m15-v2-acute-coronary/11118/resources/chapter_4.pdf
2) https://www.nice.org.uk/guidance/cg95/evidence/full-guideline-245282221
3) https://www.mdcalc.com/calc/1752/heart-score-major-cardiac-events
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Potential complications associated with STEMI include ventricular arrhythmias, heart failure, cardiogenic shock, mechanical complications (e.g., papillary muscle rupture, ventricular septal defect), and thromboembolic events (e.g., stroke, pulmonary embolism).
References:
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Early reperfusion therapy in STEMI improves patient outcomes by restoring coronary blood flow, salvaging myocardium, and reducing the extent of myocardial necrosis. It helps minimise myocardial damage, reduce the risk of complications, and improve long-term prognosis.
Multiple studies have shown the association between the “call-to-ballon” time and patient outcomes - one example from the USA is listed below
From 1994 to 2006 in National Registry of Myocardial Infarction, the median D2B time was reduced year over year in the United States from 120 to 87 minutes, which was accompanied by a steady decrease in in-hospital mortality from 8.3% to 6.6%.
References:
1) https://lms.resus.org.uk/modules/m15-v2-acute-coronary/11118/resources/chapter_4.pdf
2) https://www.ahajournals.org/doi/full/10.1161/CIRCRESAHA.114.302744
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Secondary prevention measures for this patient following the acute event should include lifestyle modifications (e.g., smoking cessation, healthy diet, regular exercise), pharmacotherapy (e.g., statins, antiplatelet agents, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers), and cardiac rehabilitation to optimise cardiovascular health and reduce the risk of recurrent events.
References:
1) https://lms.resus.org.uk/modules/m15-v2-acute-coronary/11118/resources/chapter_4.pdf
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The original case report explores the role of intravascular imaging in diagnosing plaque erosion as the underlying mechanism in patients with ACS, and highlights the effectiveness of a no stent treatment approach. It emphasises the significance of clinical and laboratory predictors in identifying patients at higher risk of plaque erosion-induced STEMI. Additionally, the potential of coronary CT angiography (CCTA) in early identification of high-risk patients is discussed.
The study demonstrates the impact of intravascular imaging and pathophysiology-guided treatment in managing STEMI without stent placement, thus avoiding potential stent-related complications. It emphasises the need for large-scale randomised clinical trials to validate pathophysiology-based treatment strategies and establish their efficacy in ACS caused by plaque erosion.
The article emphasises the personalised nature of treatment approaches and acknowledges the evolving landscape of treatment strategies. It provides a comprehensive analysis of intravascular imaging, clinical predictors, and emerging management approaches for ACS patients with plaque erosion.
In summary, this detailed analysis sheds light on the diagnostic role of intravascular imaging, the importance of clinical predictors, and the potential benefits of a no stent approach in managing ACS caused by plaque erosion. It calls for further research and large-scale trials to solidify pathophysiology-based treatment paradigms and improve patient outcomes.
Source: https://doi.org/10.3389/fcvm.2022.834676
Case Summary & Questions written by Dr Ahmed Kazie
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