Case Study: Massive Infarct or Peridcarditis

[OVeractiveBrain]

24 yo male complaining of mild chest pressure following a chemically induced stress test (dopamine infusion). Patient is an average weight african american male with "heart problems" throughout his life. This is not an occlusion, MI, nor CHF. He states he had not needed to be followed by a cardiologist but recent exertional dyspnea had brought him to one today. Non smoker, Non drinker, No familial History, No Significant Medical History save "heart," No Meds.

I dont have the 12-lead to scan, but I can describe it for you. At 15 minutes into the stress test the patient complains of a mild chest pressure and a brief fluttery feeling in his chest. The flutter correlates to a brief (10 second) span of VTach. He is in a sinus tachycardia near 130, that has not been resolved after 20 minutes at rest. He has ST segment elevations in I, II, aVL, V2-6. The st segment elevations have not been alleviated with ASA (325mg PO), Nitro (1.2mg SL), and Lopressor (30mg PO), though his VS WNL (save tachycardia) and GCS:15. His cardiologist activated the cath lab, they only awaited his arrival to the ED.

Now, the cardiologist says he needs a cath, and the lab is activated, and im 20 minutes away. Easy one down the main road in town as there was no highway. Im at the limit of my interventions save morphine, but his SYS BP is floating around 100-110, and his pain is not severe. The only treatment i had for him was calming words and talk of the future. Routine ALS of course. Alls well and good.

We get to the ER and I go talk to the Doc. I tell him the cath lab has been activated for this patient. Given his low risk (0 Framingham, except for "cardiac history") and global 'ischemia' I asked the Doctor if this wasnt more likely pericarditis. He agreed. Both that it probably is but that the lab was activated, so get him up there. Ok, so you know it wasnt ACS. Pretend you dont for what comes.

Cardiologist says ischemia, needs a cath. Im not going to contend with the cardiologist. But it turns out this kid did not have an occlusion and did not need a bypass or a stent. I think he was admitted to a cardiac floor. My only source of followup was with his nurse, who did not follow him very far. I thought the global elevations (and absence of inversions, symptomy and risk factors) were a bit suspicious.

Just for a moment, let us suspend our disbelief and instead of a cardiologist handing us a 12 lead, we get it ourselves. Same patient, without PO meds, after he got done with his morning exercises called for chest pressure. I know we already know it wasnt ACS, nor are we sure it was pericarditis. But if youve got a kid with some persistant mild angina with global elevations, despite a framingham of 0, do you activate the lab? We do not yet have the authority to activate the cath lab ourselves, but we sure as hell can initiate the process (i.e. the patient is out of the ER before as his labs come back, usually within 20 minutes). I personally was hesitant with such activation, but since I didnt make the call, it was easy to follow through. Just wondering what your thoughts were on this guy, and on "global ischemia" in the absence of severe clinical findings.

Overactive

[Ridryder 911]

Interesting case. I believe this is one of those cases, one may not really know the etiology until the post mortem. Not to be pessimistic, but such a a young age without precursors and continuation of ischemia type presentations is not a good sign.

I agree, pericarditis should had been initially suspected as well. Although the cath may had been clean, I do believe there is something "cooking', just not sure exactly what it might be. I have seen many people die after a "clean cath" from arterial coronary spasms.

In regards of activating the "cath lab", this is one of those personal calls. In most 21 y.o., I would admit, I would probably not.. then again, I had a 21 year old with a massive anterior septal wall infarct. No previous PMHX, in fact a basic EMT student and in excellent shape or co-existing conditions. So one can never say never...There was something gnawing at you to treat so aggressively.

The old saying.. if you thought you should.. you probably should had, usually is more true than anything I have found in the field. Gut instincts are there for a reason, along with some good physiological indicators. Although, this is how we continuously learn...

Interesting case, see if you can obtain further follow-up and work up.

R/r 911

[AZCEP]

Tough to judge without seeing the patient while this was happening. Some of the subtle findings get lost in the translation.

That young, without risk factors as you describe, I'd probably forgo the cath lab also. I'm sure there is something in the history that would have suggested something other than an ischemic event, but can't really say so from this information. You've described the situation very well, but there is always something left out that may well swing the decision another direction.

Luckily, an angiogram is not a terribly difficult procedure to perform, and once it is done the cardiology team will have good information to work from. It doesn't sound like this patient absolutely needed one, but that's for someone else to determine.

[vs-eh?]

For the sake of arguement as a potential differential...

Unknown sickle cell patient with an ayptical (acute chest) presentation?

Meh?

[Ridryder 911]

For the sake of arguement as a potential differential...

Unknown sickle cell patient with an ayptical (acute chest) presentation?

Meh?

Good thinking.. hopefully I would ask if there was a hx. of being a sicklar.. I usually have seen other associated symptoms though...

R/r 911

[chbare]

In addition, we need to rule out congenital conduction problems and various other syndromes such as early repolarization, WPW, and Brugada syndrome among others. Any info as to the specifics of his "heart history?" Perhaps electrophysiology/cardiac mapping would be helpful?

Take care,

chbare.

[fiznat]

Thats a tough one. The global elevations (without reciprocal depressions) is a hallmark of pericarditis, and the young age of the patient would definitely make most of us skeptical about ACS to begin with, I'd think.

It does worry, though, that the patient does in fact have a "cardiac history," and that the symptoms were brought on with exertion (I don't believe this is characteristic of pericarditis?). I remember reading that pericarditis pain is sometimes relieved/aggravated with changes of position. Did you notice this at all? What about history of infections, viral illnesses, etc?

Not that we are able to in my area anyways, but I don't think I would directly activate the cath lab on this one. More likely I would try to present the patient as clearly as possible to on-line medical control, and put the decision on them. Its one of those cases that really could go either way, and I'll be dammed if someone were to try and blame me for under treating a potentially deadly condition. Pass the buck, my friend, pass the buck.

[OVeractiveBrain]

I had not thought of sickle cell, though i would hope that some one who suffers from it would list that amongst "past medical history." I did not ask him specifically though.

No history of infections, viral or otherwise. This doesnt look to be a clear case of ACS nor pericarditis (which is probably why the cardiologist activated the cath). I worry, sometimes, though, that Internal Medicine doctors in primary care facilities (this guy was a stress-tester within a Primary Care Office), even when cardiology is their specialty, might be doing exactly what fiznat suggested... passing the buck. Since it wasnt clear cut either way (exertional onset leads towards ACS, global elevation without massive compromise suggests pericarditis) he might have been doing just that.

Sometimes I find myself struggling with concepts such as that. I assume that the cardiologist is the end-all of cardiac understanding. The more I think about it, the more I think he just wasnt sure, followed some protocol, and sent him out just in case. I suppose that is a good sign for we paramedics, because sometimes, that is exactly what we do! Treat to the best of our ability,and let some one else take responsibility down the line.

I wish I had more information about his cardiac history. It didnt seem to be anything significant, as it was not recent (something in childhood), nor did it cause him any difficulty until the past few weeks. Im sure that could push one way or another. Any of the docs that post on the forums know of any childhood or developmental diseases that predisposes an otherwise healthy young man to suffer from these symptoms. Im sure there are many, but i was thinking along the lines of a congenital defect that predisposes the patient to frequent infections or ACS without plaque development (some sort of spasm or narrowing of the lumen other than the standard processes we discuss)?

D

[fiznat]

Sometimes I find myself struggling with concepts such as that. I assume that the cardiologist is the end-all of cardiac understanding. The more I think about it, the more I think he just wasnt sure, followed some protocol, and sent him out just in case.

This is probably it, and to be honest, I don't think there is anything wrong with that. Medicine - even at the physician level - teaches us to look for signs and symptoms, to calculate odds based on history and published probability. These are subjective observations though, even in the case of the EKG and the supposed finality of cardiologist-level knowledge. Medicine's ties to science require that we all remain a bit skeptical till we've seen it for ourselves, clear as day on the angiograph. I agree with him. The potential consequences are too great to make a decision with such limited, subjective information. It deserves a direct look.

[notsobuff]

Just to stir the pot I suppose, but any chance that all of those elevations were just benign early repolarization unrelated to the chest pain?