Case presentation
A gentleman in his early-sixties presented to a remote hospital
elsewhere with a history of acute chest discomfort that was associated
with light-headedness and shortness of breath. He is a chain smoker,
non-diabetic and non-hypertensive. There was no prior cardiac history.
The electrocardiogram (ECG) showed inferior wall ST elevation myocardial
infarction with complete AV block. He was hemodynamically stable with a
heart rate of 30 to 35/mt and was referred to our centre for further
management without any revascularization attempts. He arrived 24 hours
later still in complete heart block with a heart rate ranging from 40 to
45/mt and persisting ST elevation (Fig. 1) with a blood pressure of
140/90 mmHg. A temporary pacemaker was inserted with a plan to do
coronary angioplasty. However the patient became delirious and restless
and did not allow the team to proceed. Since he was hemodynamically
stable with no ongoing angina, it was decided to delay the procedure a
little while.
While in the ward he became breathless and went into distress with low
blood pressure despite adequate pacing. He was intubated by the on-call
doctor, started on inotropes and shifted back to the cath lab for
revascularization. The coronary angiogram showed a single vessel disease
with a 100% proximally occluded right coronary artery (Fig. 2).
Complete re-vascularisation of the vessel was achieved with two
drug-eluting stents (Fig. 3) and over the next 36 to 48 hours he was
slowly taken off inotropic support (noradrenaline). On the second
post-procedure day he recovered sinus rhythm with a first degree heart
block and a PR interval of 280 ms. He was extubated the same day and
taken off temporary pacemaker support the following day. The patient was
discharged two days later maintaining sinus rhythm and a much reduced PR
interval of 204 ms (Fig 4). The echocardiogram showed a mild left
ventricular systolic dysfunction with no other mechanical complications.