Hi Sunil,
> This chap was a known arteriopath who had gone to a local community
hospital
> for ongoing eye follow-up and whilst there he had a routine ECG. It
showed
> ST elevation 4mm in V2 and 3. He was then sent to A&E. He had the
tiniest
> niggle of discomfort in his chest an hour before that had lasted five
> minutes but in A&E he had no pain and was sitting there happy as a sand
> boy!. Nor had he had any significant episode of relevant symptoms within
> the last 48hrs.
His age would be interesting to know given teh recent report on over 75s
not doing so well with thrombolysis.
>
> Question: Would you have thrombolysed him purely on the ECG as he had no
> contraindications?
No I would not. We are forever seeing patients with persistent ST segment
elevation after MIs which are often ventricular anurysm particularly in
arteriopaths like your chap. I would have searched hard for an old ecg: GP
? Hospital Notes ? CCU ? Previous A&E record ? Of course in another few
years we would just check his electronic record which he has brought with
him containing all his medical history and the result of every investigation
he has ever had or if he doesn'nt have it with him we will check it off the
mirror site which will be kept on teh NHS web ! Near patient testing of
trop T, myoglobin or CKmb might also be helpful.
> Repeat ECGs showed that his STs came down over the course of an hour but
> even then were approx 2mm above baseline. Anyway, what did I do.
> Thankfully I'm in a teaching hospital at the moment and so I referred him
to
> a cardiologist who arranged angiography which showed 95, 90 and 90%
stenoses
> and he's had a CABG 4 days later!. Good for him that he didn't pitch up
at
> a local DGH without these facilities.
Was I wrong not to thrombolyse him ? Well he didn't infarct did he ? And
how many 'known arteriopaths' do you know wandering around with virgin
coronary arteries ? What do you think we would find of we were to angio
every arteriopath who gets a 5 minute 'niggle' in his chest ? I think what
is more important here is the changing ECGs
regards
john Ryan
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