47 years old man, smoker, hypertension presented with the worst central chest pain three hour prior to presentation. The pain is sharp in nature, radiate to the right chest, left arm and shoulder, persistent in nature, pain score 7/10 and associated with diaphoresis and vomiting.
On arrival BP 227/137, PR 82, RR
24, SPo2 99% and pain score 7/10.
He is conscious and alert, in
distress, pink, good hydration and perfusion status. cardiovascular exam shows
S1S2 with no murmur, lung field reveal very minimal basal crepitation and
abdominal exam is normal.
First ECG shows sinus rhythm, left
axis deviation, ST elevation of lead I, AVL, V1-V6 with reciprocal ST
depression at lead III and AVF.
Repeated ECG after three minutes
shows similar finding
A diagnosis of hypertensive
emergency with Extensive anterolateral MI was made.
S/L GTN I/I, Tablet Aspirin 300 mg,
Tablet Clopidogrel 300 mg was given stat. Blood pressure was stabilized with IV
morphine, IV GTN infusion and bolus of hydrallazine and IV streptokinase was
infused in a slow manner, according to BP control.
Post streptokinase shows return of
the ST elevation at I, AVL V5-V6 to baseline, reduction in ST Elevation height
in V1- V4, Q wave formation with slow R progression in lead V1-V3 and T
inversion in lead V1-V6.
In view of pain reducing in
severity and patient more comfortable, streptokinase infusion is acceptable.
But patient require urgent PCI as clot is not fully resolve.
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