Mr Kumar (name changed), age 42, was in his office when he felt severe chest pain. He was taken to the nearest hospital within the critical one hour. There he was admitted for Acute Anterior Wall Myocardial infarction. He was administered Fibrinolytic agent Reteplace and standard Antiplatelet drugs. With this, the chest pain and ECG evidence of reperfusion came down. Further, diagnostic tests coronary angiography and Echo were conducted the next day.
ECG before & after fibrinolysis
Mr Kumar was then shifted to the K J Somaiya Super Specialty Centre (KJSSC) for specialised Cardiac Care under the expert hands of Dr Sadanand Shetty, Consultant Cardiologist, KJSSC.
The angiography showed evidence of obstruction (block) in the Proximal LAD along with thrombus; however, the degree of severity of the block was not clear.
The patient was treated with standard antiplatelet drugs and Stalins for five days at the K J Somaiya Hospital Super Specialty centre ICU.
Explains Dr Shetty ‘ Two main arteries supply blood to the muscles of the heart, but the LAD (left anterior descending artery) typically supplies over half of the heart muscle with blood. Significant blockages of the LAD artery can be dangerous simply because the LAD supplies blood to such a large territory.
The doctors discussed the treatment plan with the family and the patient, explaining the need to conduct an angiography again on the 8th day after the myocardial infarction with a plan of doing FFR, in case the block was borderline. The angiography showed complete clearance of thrombus, with evidence of 90 % Obstruction in the Proximal LAD.
Seeing the severity of the blockage, an Angioplasty procedure with Drug-eluting Stent 3rd Generation was done using Radial Artery Approach (Right hand).
The patient responded well to the procedure and was discharged the next day.
Dr Sadanand Shetty, Consultant Cardiologist, K J Somaiya Hospital, Super Specialty Centre, shares his insights.
– A Few Learning Points from this case.
- Fibrinolysis (Releplace) is a beneficial life-saving drug in Myocardial infarction (MI). Earlier the drug is given after Chest Pain of MI; better is the patency rate.
- Angiography once fibrinolysis is done, to quantify the obstruction in the artery so that that appropriate treatment could be planned.
- If Angiography shows, good TImi flow in the artery as well as significant thrombus, then antithrombotic drugs should be given to dissolve the thrombus, so that we can judge the severity of block better & the complication rate of thrombus during angioplasty can be minimised/avoided.
- If in doubt, using FFR after approximately seven days of MI, to judge the severity of block is a very useful modality. ( Waiting time adequate to avoid false negative FFR because of microvascular clogging.
- Faith & Trust in the patient care, to improve doctor-patient relationship, so that right decision at the right time very useful.
- Overall faith in the hospital, is also essential for such very specialised type of care such as FFR, Transradial Angioplasty, Using Rotablator, imaging