Which of the following conditions does not justify immediate coronary angiography and, if needed, revascularization?
A 65-year-old man known for CAD complaining of progressive shortness of breath since 1 week. At admission, no ongoing chest pain with stable hemodynamic status but bibasilar rales at lung auscultation. The ECG revealed ST-segment elevation as well as Q waves in the anterior leads. The 2011 AHA/ACC PCI guidelines elaborated indication of PCI in patients with STEMI. 5 Primary PCI should be performed in patients within 12 hours of onset of STEMI, within 90 minutes of the first medical contact in patients presenting to a hospital with PCI capabilities and within 120 minutes of the first medical contact in patients presenting to a hospital without PCI capabilities (“systems goal”). Primary PCI should be performed in patients with STEMI who are candidates for primary PCI, who develop severe heart failure or cardiogenic shock irrespective of time delay, and who had clinical and/or ECG evidence for ongoing ischemia between 12 and 24 hours after symptom onset. Delayed PCI in patients with STEMI is reasonable in patients with infarct artery reocclusion or demonstrating ischemia on invasive testing. PCI of hemodynamically significant stenosis in patent infarct artery greater than 24 hours after STEMI might be considered as part of an invasive strategy (class of recommendations IIb). PCI of a totally occluded infarct artery greater than 24 hours after STEMI should not be performed in asymptomatic patients with one- or twovessel disease if patients are hemodynamically stable and do not present evidence of severe ischemia (class III).
A 76-year-old man with no prior cardiac history presents to the emergency department with acute retrosternal chest pain. He had a single episode of chest pain lasting 4 hours 5 days ago. At that time he did not seek medical attention. Physical examination reveals a slightly confused diaphoretic patient, with heart rate of 95 bpm, blood pressure of 76/42 mmHg, and cold extremities. He is able to lie flat, the lungs are clear, and the jugular veins are distended even if the upper part of the body is raised at 45°. On cardiac auscultation a loud systolic murmur is audible, while on ECG Q waves associated with ST-segment elevation are detected in the inferior leads. The most likely diagnosis is:
Right ventricular infarction. Rupture of the interventricular septum is one of the mechanical complications of MI, less frequent than left free wall rupture. It occurs in general 3 to 5 days after acute MI. An increase in risk is observed in patients with occlusion of LAD wrapping the distal inferior wall and inferior septum (inferior MI with large anterior MI). The ECG findings of the interventricular septum rupture are typical for ST elevation and Q waves in the inferior leads II, III, and aVF. Clinically, the patients present a rapid onset of hemodynamic compromise characterized by hypotension, biventricular failure, and a new harsh, loud, holosystolic murmur best heard at the lower left sternal border.
A 76-year-old man with no prior cardiac history presents to the emergency department with acute retrosternal chest pain. He had a single episode of chest pain lasting 4 hours 5 days ago. At that time he did not seek medical attention. Physical examination reveals a slightly confused diaphoretic patient, with heart rate of 95 bpm, blood pressure of 76/42 mmHg, and cold extremities. He is able to lie flat, the lungs are clear, and the jugular veins are distended even if the upper part of the body is raised at 45°. On cardiac auscultation a loud systolic murmur is audible, while on ECG Q waves associated with ST-segment elevation are detected in the inferior leads.
Considering the suspected diagnosis for the patient is right ventricular infarction, what is the next diagnostic step?
Immediate coronary angiography. The septal defect and the associated turbulent transseptal flow can be visualized by a transthoracic echocardiography using color flow Doppler imaging. The addition of Doppler to echocardiography improves significantly the sensitivity of the examination demonstrating the transseptal turbulent flow and diastolic– systolic turbulences in the right ventricle.
While considering surgery for the patient described in the previous two questions, the most effective cardiac unloading treatment for him is:
Mechanical ventilation with positive end-expiratory pressure. The timing of surgical repair with post-MI ventricular septal rupture is controversial. In patients with cardiogenic shock, a fatal prognosis is inevitable in the absence of urgent surgical treatment. First, stabilization with an intra-aortic balloon pump counterpulsation, inotropic agents, diuretics, and, if tolerated, vasodilators is attempted. This is followed by cardiac catheterization to define the coronary anatomy and then surgical repair.
A 66-year-old man with a history of diabetes was referred for coronary angiography. The procedure showed complex multivessel disease.
Which of the following statements justify the use of DES over BMS?
All of the above. The 2011 ACC/AHA PCI guidelines assessed the risk– benefit profile for the use of BMS versus DES. DES is preferred to BMS when high risk of stent restenosis is present with BMS. The clinical situations associated with higher risk of restenosis are:
All the criteria mentioned above increased the risk of restenosis, suggesting the use of DES over BMS.
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