Inferior infarction, evolution after fibrinolysis

Tracing
N° 34
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Patient
51-year-old man, smoker, hypertensive, hospitalized in a peripheral hospital for typical constrictive chest pain, unresponsive to sublingual nitroglycerine initiated 4 hours earlier;
Inferior infarction, evolution after fibrinolysis
Inferior infarction, evolution after fibrinolysis
Inferior infarction, evolution after fibrinolysis
Inferior infarction, evolution after fibrinolysis
Inferior infarction, evolution after fibrinolysis
Inferior infarction, evolution after fibrinolysis
Comments

This patient presented with an inferior myocardial infarction requiring fibrinolysis therapy. Secondary coronary angiography revealed a severe stenosis of the second segment of the right coronary artery (absence of thrombus indicating the efficacy of fibrinolysis); this patient received angioplasty with stent placement. Ultrasound showed inferior hypokinesia with a left ventricular ejection fraction evaluated at 55%.

This patient presented various signs of effective reperfusion after fibrinolysis: rapid disappearance of pain and segment elevation, ventricular couplets in conjunction with pain cessation, premature T-wave inversion in the territory previously presenting with elevation.

As a result of the thrombosis of a coronary artery, reperfusion may sometimes be spontaneous or occur as a result of fibrinolysis treatment or emergency angioplasty. In the absence of reperfusion, ST-segment elevation usually regresses within 12 to 24 hours with the appearance and persistence of necrosis Q-waves in the culprit territory. When fibrinolytic treatment is performed, certain clinical and electrocardiographic signs are suggestive of effective reperfusion.

At a time when coronary angiography was not yet available, it was not possible to directly visualize the resumption of flow and the following signs were the only signs allowing to suspect reperfusion:

  • an early regression of the amplitude of the elevation (>50% within a few minutes) is a good indicator of a resumption of myocardial perfusion and is most often associated with resolution of the anginal symptomatology and a recovery of segmental myocardial contractility; the rapid regression of the elevation is a factor of good prognosis;
  • an early inversion of the T-wave (observed within 2 hours after the initiation of fibrinolysis) in the leads that exhibited the elevation is also a very specific sign of reperfusion;
  • reperfusion arrhythmias are frequent and are most often benign; the appearance of isolated ventricular extrasystoles, in couplets (as in this patient) or in short nonsustained  bursts is frequently observed during reperfusion; an AIVR (accelerated idioventricular rhythm), corresponding to a focal ventricular rhythm (between 60 and 120 bpm), occurs in about 50% of patients with effective reperfusion; these reperfusion arrhythmias are usually transient and only last a few seconds or minutes and do not require any particular treatment;
  • in certain patients with inferior or posterior infarction, reperfusion may be accompanied by the occurrence of a transient sinus bradycardia which may temporarily alter the hemodynamics of the patient;
  • in contrast, the persistence of pain and of the elevation, the presence of a hemodynamic instability are indicative of an absent or incomplete reperfusion; similarly, the occurrence of sustained monomorphic ventricular tachycardia should not be considered as a sign of reperfusion.
Epigraph
Following fibrinolytic therapy, various clinical and electrocardiographic signs are suggestive of an effective reperfusion: rapid resolution of anginal symptomatology, regression of the elevation, occurrence of reperfusion arrhythmias, early appearance of a negative T-wave.