Would you thrombolyse this?
Thrombolysis is scary even in an obvious case (so much nicer to be able to send a patient to a cath lab)
But the decision is often even more difficult when the history and/or ECG is not classical.
NB the consensus (not unanimous) from several international ECG/EKG gurus (see below) is that this patient SHOULD NOT HAVE BEEN THROMBOLYSED. See Lessons Learned below.
A man in his 40s was brought into ED by ambulance. He is paraplegic with a T8 sensory level from a car crash many years ago (and therefore likely altered sensation of cardiac or other pain). Earlier this year he has had a non-STEMI with conscious VT which presented with only shortness of breath. He had a proximal LAD stent and an implantable defibrillator inserted. He had had another presentation with shortness of breath during which he was thrombolysed for ST elevation which turned out to from an LV aneurysm.
On the day of this presentation he had woken at 0700 with epigastric pain which he attributed to an alcohol binge and sitting for too long the night before. He had finally been brought into ED 11 hours post onset of pain
On arrival in ED he was sweaty, tachypnoic and drowsy. His feet were purple, which he said was abnormal of him. His vital signs were normal. Bedside ultrasound of chest, abdomen, aorta and pericardial space were normal.
This was his ECG:
This is his ECG from his previous admission:
I struggled with this ECG. He had a LBBB configuration, but no concordant ST changes to fit the Sgabossa criteria, but that ST elevation in V5 doesn’t look like LBBB and is markedly different from his old ECG. He was still in pain and still sweaty.
I discussed with the patient the risk and benefits of thrombolysis, my uncertainty about the ECG, and the late presentation. He requested thrombolysis.
He was given a thrombolytic, his pain and sweating resolved, and his ECG improved. His troponin was 0.25 (normal < 0.03).
Post thrombolysis ECG:
I solicited an opinion from Amal Mattu, ECG guru, on this case. Here is his tweet:
I love it that Amal Mattu gives opinions to random bloggers in far off lands
- If in doubt get a second opinion before you thrombolyse!
- ST segment amplutude and shape can change significantly with rate (especially in the presence of an LV aneurysm).
- Myocardial pain is carried T3-5.
- A young man (with T3-5 sensation intact) without chest pain is unlikely to have myocardial ischaemia.
- A QRS complex with only a negative component is called a QS complex
- Even the experts disagree on what is a LBBB