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.