July 14, 2013

Image of the Day 20: Inferolateral MI with Posterior Wall involvement and Hypertensive Emergency

45 years old gentleman who is a chronic smoker and underlying hypertension presented with typical chest pain 1 hour prior to presentation associated with diaphoresis, nausea and vomiting and one episode of fainting at workplace.

Vital sign upon arrival as follow; RR 18/min, PR 74/min, Temp 36.4 degree Celsius, SpO2 100% under room air, BP 198/131, repeated 193/132. CSS is full.

On examination, patient is fully conscious and alert, in severe pain (pain score 10/10), pink, Hydration and perfusion status is good, not tachypnoeic and not tachycardic. Examination of Respiratory, Cardiovascular and Gastrointestinal system are unremarkable.

Initial ECG taken at triage shows sinus rhythm with rate of 75, ST elevation at lead II, III, aVF, V4-V6 and reciprocal ST depression with T inversion in lead V1-V3.

Initial ECG

Patient was triage at red zone. 100% oxygen was delivered via non rebreather high flow mask. Two large bore IV line was set up. Sublingual GTN was given for two times but the pain was not resolving. Therefore, IV Fentanyl 100 mcg stat was given together with IV  metaclopromide 10 mg. Pain score was reduce to 5/10.

Repeated ECG after 5 minutes of presentation shows similar finding. Right sided ECG was done and did not reveal any right wall involvement. A diagnosis of Inferolateral MI with involvement of posterior wall and hypertensive emergency was made.
5 minutes later

Right sided ECG shows normal V4-V6 indicating no right wall involvement

IV GTN infusion 50mg diluted in 50 cc NS was started at the rate of 0.3 mcg and titrated accordingly to control the blood pressure. Tab Captopril 25 mg stat was served as well. However, BP was remained in a higher side 180/130. Therefore, IV hydrallazine infusion was added and BP was managed to be reduced to 140/106.

Pain score was persistently 5/10 and patient was given IV morphine 2.5 mg stat.

After evaluation, patient is found to be suitable for thrombolytic therapy. However, in view of persistently high BP, the duration of thrombolytic therapy was extended from 1 hour to two hours. IV streptokinase 1.5 Million IU was diluted in 100 ml of normal saline and infuse over 2 hours.

Throughout infusion, patient was complicated with hypotensive episode of 70/64 and borderline bradycardia of 60 b.p.m. Antihypertensive agent was off and IV streptokinase was withhold. A fluid challenge of 250 cc NS was infuse as rapid bolus and BP pick up to 100/70. IV streptokinase was then continued and completed after two hours and 15 minutes.

Post thrombolytic ECG was taken and it shows return of ST elevation to the baseline. Patient was disposed to Coronary Care Unit for further management


  1. Love to ask, in what basis, Iv streptokinase need to be started in this patient?

    Lee - Ortho

  2. streptokinase is a thrombolytic.. it used to dissolve the clog inside the coronary artery.. thrombolytic therapy is for ST elevation myocardial infarction


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