> Surely if you´ve got a good going ECG showing anterolateral
> infarct, Matt, then it doesn´t much matter how good or how
> bad the chest pain history is?
Never come across a ECG showing anterolateral infarction, so I wouldn't
know. I've seen ECGs showing ST elevation, ECGs showing T wave inversion and
ECGs showing Q waves, but I don't believe you can diagnose MI on the basis
of a 12 lead ECG without clinical or radiological confirmation. I think the
reason they ask for 30 minutes of chest pain for thrombolysis is to
distinguish from subendocardial or subepicardial ischaemia or Prinzmetal's;
but in this case relevant (and reasonably likely) differential of ST
elevation (assuming that was what the diagnosis was based on and we're happy
it's not an early repolarisation or part of LVH) included SAH; direct trauma
from CPR; and less likely myocarditis with focal pericarditis or Brugada
syndrome with vertical axis rotation of the heart.
This is a patient with fairly low risk factors for MI, presenting without a
typical history. I wouldn't be too happy about her chances of having a MI
based on the ECG alone (several papers out there showing only a minority- in
some cases a pretty small minority- of patients coming to A and E with ST
elevation have an acute MI). Given the uncertain diagnosis and the relative
contraindications, I'd more away from thrombolysis here.
Matt Dunn
Warwick
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