A partial list of chest pain in the “Post-Infarction” period
Posted May 21 2012 11:07pm
We know prompt reperfusion of infarct related artery( IRA) by any means constitute the specific management of STEMI .However, It needs to be emphasized , treatment process of STEMI is not over after primary PCI or thrombolysis .Early hours after a PCI or thrombolysis is vital as well .The ill-fated coronary arteries are as vulnerable as before. In the setting of multi-vessel CAD (Which usually is the case) the unpredictability is still more.
Image courtesy New york times , January 5 , 2009
When a patient complaints of chest pain 24 hours after a STEMI . Think about any of the possibilities and act accordingly.
Infarct related pain( Dull aching pain from residual neural signals from infarct zone, till type C un-medullated nerve endings die of hypoxia )
Post infarct angina -From IRA zone (Residual ischemia)
Post infarct angina-From Non IRA zone(New Remote ischemia)
Infarct expansion/ Extension /mechanical stretch
Intra coronary dissection adjoining a plaque (Plaque fissures are same as dissections if they extend into media ! But plaque fissures are painless since they lack nerve endings )
Myocardial tear/Rupture (Generates severe pain , usually transmit to back , patient often become violent and poorly respond even to narcotics)
Post resuscitation/DC shock / chest wall contusion . ( I know at least one patient who was rushed to cath lab for a suspected acute stent thrombosis , it was indeed a rib fracture during an earlier resuscitation at ER on his arrival !)
Finally ,when the pain is refractory and atypical non cardiac chest pain which might have been pre existing to be considered as remote possibility .