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Angiography can have bleeding complications - be more sure of your STEMI diagnosis in high risk patients

Posted Aug 31 2012 10:48am
An over 90 yo patient complained of 1 hour of chest pain.  There was a h/o CAD with CABG.  The prehospital BP was 200 systolic.  The paramedics recorded an ECG which could not be obtained but which was identical to the ED ECG recorded here:
There is sinus rhythm.  There is some STE in aVL, with reciprocal ST depression in II, III, aVF, and STD in V6.  There is also a QR-wave in aVL,  consistent with old MI.  Although one might be worried about acute MI here, it is likely that the ST elevation, without large T-wave and with Q-wave, is due to old MI (LV aneurysm morphology).
The paramedics activated the cath lab.  The CP resolved with NTG and ASA, and the ED BP was 170/90.  She was given heparin and abciximab and taken to the cath lab.  There were several severe chronic calcified lesions, no culprit, and no PCI was performed.

However, there were severe bleeding complications and she died of a retroperitoneal hemorrhage.

There are several lessons one can be reminded of by this case
1. Not all ST elevation is acute STEMI
2. Acute STEMI usually has large T-waves and, unless anterior, does not develop Q-waves rapidly.  When you see inferior or lateral QR-waves, think of old MI with persistent ST elevation.
3. Hypertension can cause ischemia with chest pain
4. If the pain goes away and the ECG is equivocal, then slow down
5. PCI has risks, mostly bleeding risks, and these are much higher in the elderly, especially women

Bleeding Risk Factors  in PCI

GRACE registry 24000 patients; Eur Ht J 24:1815; 2003  

Major bleeding definition: life threatening:
  • Transfusion of ≥2 units PRBC or
  • Decrease in hematocrit of ≥10% or
  • Intracranial hemorrhage or
  • Death
  • The overall incidence of Major Bleeding in PCI
  • 4.8% in patients with STEMI
  • 4.7% in patients with Non-STEMI
  • Risk Factors for Major Bleeding in PCI
    • Advanced age
    • Female sex
    • History of bleeding
    • Renal insufficiency
    • (Diabetes and stroke in other studies)
    • After adjustment, major bleeding is:
    How to Lower Risk in High Risk Patients 
    Assess risk benefit

    Be more certain of diagnosis

    High risk vs. lower risk STEMI
  • Anterior vs. other locations
  • Poor LV function on echo
  • Hemodynamics (shock, blood pressure, pulse)
  • Pulmonary edema
  • ST score (how many leads involved? How widespread?)
  • Ongoing symptoms (vs. resolved)
  • Resolution of ECG findings associated with much lower risk
  • Appropriate dosing of Heparin
    60 U/kg Loading dose: IBW + 0.4(TBW-IBW), maintenance 12 U/kg/hr: IBW + 0.4(TBW-IBW)

    Use of bivalirudin
  • (always with clopidogrel) vs. heparin + abciximab
  • Radial artery access
    Clopidogrel 300 mg, vs. 600 mg, vs. Prasugrel, vs. Ticagrelor (the latter have less ischemia, more bleeding)
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