The Pains of Separation

When a patient arrives to your ED fresh from karate class still in her uniform, you get a feeling about where the case is heading. This patient was 49, and reported that she always had some aches after karate. This evening, though, her pain was very different — and much more concerning. The pain had started about an hour into her class and worsened over the next 30 minutes. It was a severe achy pain over her left chest that radiated to her neck and was associated with pronounced diaphoresis. This prompted an expedited cardiac workup.   The ECG showed a sinus tachycardia with ST-elevation in V2-V3, I, aVR, aVL, with depression in II, III, aVF, and V5-V6. The ST-elevation in V2-V3 with inferior reciprocal depression (II, III, aVF) was concerning for myocardial injury in the anteroseptal region caused by left anterior descending artery (LAD) occlusion. EPs should have a high suspicion for very proximal LAD, left main, or Circumflex occlusion when seen in conjunction with ST-elevation in I, aVL, and aVR.   Figure 1.   She was taken immediately for coronary angiography, and was found to have an extensive thrombosis originating in the left main and extending into the proximal LAD and Circumflex arteries. The clot was removed by aspiration thrombectomy, and further angiography and intravascular ultrasound revealed dissection of the coronary arteries originating in the left main and propagating down the LAD. A small perforation of the LAD was seen just proximal to the first di...
Source: Spontaneous Circulation - Category: Emergency Medicine Tags: Blog Posts Source Type: blogs