Case of the Month
February 2010
A 47 year-old male, with a history of hypertension, presented with chest pain. He was in his usual state of health until approximately 48 hours prior, when he developed a migraine headache. He took Imitrex, but felt weak and nauseated most of the following day. He developed SSCP at around 11:00, while on the job at a power plant. He later told his shift manager, a Paramedic, who then performed a 12 lead at 14:06 at the plant.
An inferior STEMI was suspected. The shift manager/paramedic faxed the ECG to his brother, an ED physician at Centra Lynchburg General Hospital. The diagnosis of an inferior STEMI was confirmed. Halifax Rescue took the patient to an LZ near a local school, where Medflight 3 picked him up and transported him to Centra Lynchburg General Hospital. Upon arrival he was complaining of continued severe chest pain. His blood pressure was 123/80 and HR 89. The physical exam was otherwise unremarkable.
Hospital Course: The patient was started on aspirin, Integrilin and administered a heparin bolus, and then taken to the Cardiac Cath Lab. Coronary angiography revealed an occluded mid right coronary artery. This was stented with a 3.5 by 28 mm Promus stent with excellent results.
He was found to have distal circumflex and ramus disease that will be treated medically. Left ventriculography showed inferior hypokinesis with an estimated EF of 50%. The E2B time (EMS contact at a site 65 miles away, to device activation at Centra Lynchburg General Hospital) was 97 minutes, and the D2B time (helicopter arrival at Centra Lynchburg General Hospital to device activation) was 20 minutes. The patient did well post procedure, with a peak CK of 1388 and TnI 26.91. He had a brief run of NSVT, but otherwise remained stable. He was discharged home on hospital day #2 with plans to enroll in Cardiac Rehab.
By: Peter O'Brien, MD, FACC
Centra Health, Lynchburg