Inferior ST Elevation Myocardial Infarction Research Articles

THE INTELLIGENT USE OF ADRENALINE

Abstract Case Report A 52–year–old patient experienced anterior and inferior ST–elevation myocardial infarction, leading to cardiogenic shock necessitating invasive hemodynamic and pharmacological support. During angiography, an intra–aortic balloon pump (IABP) was inserted, and a norepinephrine infusion along with dobutamine was initiated, showing partial clinical and laboratory improvement. Critical disease in all three vessels was detected, prompting angioplasty with stenting of the right coronary artery and left anterior descending artery. Echocardiography revealed severe reduction in left ventricular systolic function (ejection fraction 10%). Despite revascularization and intensive support, the patient‘s hemodynamic status deteriorated (SCAI D), necessitating the addition of adrenaline (0.03 μg/kg/min) to the ongoing dobutamine infusion, suspending noradrenaline. Subsequent days showed gradual improvement, allowing for withdrawal from amine support and discontinuation of the IABP. Follow–up included a cardiac MRI displaying severe systolic dysfunction (EF 21%), extensive ischemic–pattern delayed enhancement across three–vessel distribution. Given the persistent severe left ventricular dysfunction, the patient underwent subcutaneous defibrillator implantation for primary prevention after optimizing anti–remodeling therapy. Despite optimized medical therapy and cycles of levosimendan, the patient experienced heart failure exacerbation, requiring hospitalization (INTERMACS 3). Considering the clinical condition and absence of contraindications, the patient was listed for heart transplantation. Due to refractory hemodynamic instability despite inotropic agents, a left ventricular assist device was implanted as a bridge to transplantation. Roughly 6 months later, the patient successfully underwent heart transplantation without acute complications. Conclusions Very low doses of adrenaline demonstrate increased sensitivity to β2 receptors over α receptors, thereby enhancing mean arterial pressure and peripheral perfusion. At the cardiac level, it induces an increase in both heart rate and coronary blood flow, while peripherally reducing resistances, predominantly due to the prevalence of β2 receptors in skeletal muscle. This improvement contributes to the enhancement of ventricular–arterial coupling. In conditions characterized by a primary pump deficit, such as cardiogenic shock, the use of low–dose adrenaline emerges as a valid therapeutic option.

What if youth is not enough? Acute coronary syndrome in young patients

Abstract Funding Acknowledgements None. Background Acute Coronary Syndromes (ACS) are the leading cause of mortality in Spain. Further research is needed in order to know risk factors and outcomes in young patients so that medicians could optimize their management and prevention. Purpose Identifying risk factors, clinical characteristics and short-term outcomes in Acute Coronary Syndrome in patients aged 40 and under. Methods A retrospective analysis of patients under 40 years of age who were admitted for ACS, out of 3,859 ACS admissions in Cardiology Intensive Care Unit (CICU) in our hospital between 2012 and 2022. Results 67 patients (1.73%) were included, most of them were males (83.6%). Baseline characteristics are summarized in Table 1. 77.6% had hypertension (HTA), 22.4% had diabetes (DM) and 34.3% had dyslipidemia (DLP). 79.1% were smokers, 9.1% had a history of alcoholism and 29.9% were cocaine users. None of them had a history of stroke, atrial fibrillation (AF). Only 3% had ischemic heart disease. 68.7% of them were ST-elevation myocardial infarction (STEMI) and inferior STEMI was the most common (38.7%). In anterior STEMI (22 patients), 15 had a severe lesion in the mid-left anterior descending artery (LAD), and 6 in the left main stem (LM). Single-vessel disease was the most common (70.8%), with 3-vessel disease in 4.6%. 75.8% received percutaneous coronary intervention (PCI), and 3% underwent bypass surgery. During admission, 10.5% progressed to Killip class III-IV. The ICU mortality was 1.5%. 9% received vasoactive drugs and 4.5% were intubated. Non-invasive ventilation was used in 3% and high-flow nasal cannula oxygen therapy in 5.3%. 3% received intra-aortic balloon pump support and 1.5% underwent dialysis or ultrafiltration. 4.5% received an implantable cardioverter-defibrillator (ICD), although none of them developed bundle branch block or atrioventricular node block, nor AF. After discharge, 11.1% had recurrent ACS, and up to 5.6% underwent PCI again, with a mortality rate of 11.8%. Conclusion Approximately 2% of ACS occur in people younger than 40 years of age. Substance abuse (smoking, cocaine and alcoholism) becomes more prevalent in this group. Prevalence of comorbidities (such as diabetes and nephropathy) are lower, making them less prone to short-term heart failure. However, they are more susceptible to recurrent ischemic events. There is a high incidence of inferior STEMI and LM-STEMI. For these reasons, medicians may need to find out a substance abuse in this group and further research into other risk factors, such as coronary disease family history.Basal characteristicsClinical evolution of patients

Effect of reperfusion time on right ventricular remodeling in inferior ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Background: Right ventricle (RV) remodeling and dysfunction are frequent in inferior ST-elevation myocardial infarction (STEMI) patients and possibly implicated to poor outcomes. Objective: The purpose of this study is to investigate the influence of reperfusion time on RV remodeling in patients with inferior STEMI who had primary percutaneous coronary intervention (PPCI).Methods: The subjects were patients with inferior STEMI who had undergone PPCI and met the inclusion and exclusion criteria. From September 2021 to April 2022, samples were taken in the order in which they arrived at the Dr. Sardjito Hospital in Yogyakarta, Indonesia. To investigate the occurrence of RV remodeling, 2D-transthoracic echocardiography was performed before PPCI as baseline and 3-months after PPCI. Confounding factors were investigated using bivariate and multivariate analysis.Results: The RV remodeling was observed in 12 (28.6%) of 42 inferior STEMI patients undergoing PPCI. The RV remodeling group had a longer median reperfusion time (798.5 vs 710 minutes, p=0.568). The baseline RV end-systolic area (RVESA) and RV end-diastolic area (RVEDA) had significant correlations with the occurrence of RV remodeling (p=0.046; p=0.008, respectively). The tricuspid annular plane systolic excursion (TAPSE) rose considerably in both groups during the 3-month follow up. There were significant variations in RVEDA and RV basal diameter in the RV remodeling group, but there was a substantial rise in fractional area change (FAC) and RVESA in the non-RV remodeling group.Conclusion: In patients with inferior STEMI undergoing PPCI, reperfusion time showed no significant effect on RV remodeling.

Clinical significance of R-wave amplitude in lead V1 and inferobasal myocardial infarction in patients with inferior wall myocardial infarction.

To assess electrocardiogram (ECG) for risk stratification in inferior ST-elevation myocardial infarction (STEMI) patients within 24 h. Three hundred thirty-four patients were divided into four ECG-based groups: Group A: R V1 <0.3 mV with ST-segment elevation (ST↑) V7-V9, Group B: R V1 <0.3 mV without ST↑ V7-V9, Group C: R V1 ≥0.3 mV with ST↑ V7-V9, and Group D: R V1 ≥0.3 mV without ST↑ V7-V9. Group A demonstrated the longest QRS duration, followed by Groups B, C, and D. ECG signs for right ventricle (RV) infarction were more common in Groups A and B (p < .01). ST elevation in V6, indicative of left ventricle (LV) lateral injury, was more higher in Group C than in Group A, while the ∑ST↑ V3R + V4R + V5R, representing RV infarction, showed the opposite trend (p < .05). The estimated LV infarct size from ECG was similar between Groups A and C, yet Group A had higher creatine kinase MB isoform (CK-MB; p < .05). Cardiac troponin I (cTNI) was higher in Groups A and C than in B and D (p < .05 and p = .16, respectively). NT-proBNP decreased across groups (p = .20), with the highest left ventricular ejection fraction (LVEF) observed in Group D (p < .05). Group A notably demonstrated more cardiac dysfunction within 4 h post-onset. For inferior STEMI patients, concurrent R V1 <0.3 mV with ST↑ V7-V9 suggests prolonged ventricular activation and notable myocardial damage. RV infarction's dominance over LV lateral injury might explain these observations.

Limitation of Marginal Arteries Flow and Its Impact on Clinical Prognosis In Patients with Acute Inferior ST-Elevation Myocardial Infarction treated with primary Percutaneous Coronary Intervention

Limitation of Marginal Arteries Flow and Its Impact on Clinical Prognosis In Patients with Acute Inferior ST-Elevation Myocardial Infarction treated with primary Percutaneous Coronary Intervention

A Rare Case of Pyopneumopericardium Diagnosed by Coronary Angiography in a Patient Presented as STEMI

Abstract Pyopneumopericardium is a rare pathology with a poor prognosis. Accurate diagnosis may be difficult and, in very rare cases, can mimic ST-elevation myocardial infarction (STEMI). We present the case of a 44-year-old man, with clinical, ECG, and ultrasound criteria of inferior STEMI. Emergency coronary angiography excluded obstructive coronary artery disease. However, a hydroaeric level image in the pericardium drew our attention. The chest computed tomography scan and Gastrografin study confirmed the diagnosis of pyopneumopericardium. An exploratory thoracotomy was performed to drain the liquid from the pericardium, without highlighting a fistulous path. The etiology of the pyopneumopericardium was detected by performing an upper endoscopy, which revealed a complex lesion suggestive for a foreign body perforation, which was treated with a covered esophageal stent. The outcome of the patient was unfavorable despite the complex treatment, with cardiac arrest and death occurring on the 14th day of hospitalization.

Rare Presentation of Myocardial Ischemia in a Patient with an Anomalous Right Coronary Artery

BACKGROUND: Coronary anomalies are coronary patterns that occur rarely in the general population. The most common type of these anomalies is the emergence of the right coronary artery (RCA) from the left coronary sinus, which in most patients is either asymptomatic or leads to sudden cardiac death (SCD). THE CASE: This case report presents the case of a 35-year-old male patient who had an inferior ST elevation myocardial infarction (STEMI) for which percutaneous coronary intervention was attempted and failed due to the patient going into cardiac arrest. The patient was subsequently managed medically in the cardiac intensive care unit and followed up outpatient with a cardiologist. The patient experienced symptoms of exertional angina and had a CT angiography of the heart and coronary vessels that identified an anomalous RCA emerging from the left coronary sinus. He was diagnosed with an anomalous RCA with malignant take-off from the left coronary sinus, and subsequent management was surgical with a coronary artery bypass graft (CABG) x1 using the right internal mammary artery (RIMA to RCA). Intraoperatively, the patient was found to have sclerosis of the RCA proximally for about 5cm. The patient did well post-operatively and had no symptoms of exertional angina upon outpatient follow up with both his cardiologist and cardiothoracic surgeon. CONCLUSION: Most cases of coronary anomalies have been found to be either completely asymptomatic or lead to SCD, especially in young patients, however very few cases in literature identified patients with this anomaly presenting with STEMI such as in this case. Another significant finding in this patient is sclerosis of the RCA, where although some articles propose that anomalous coronary arteries may be more susceptible to atherosclerosis, others conclude that there may be no association; concluding that factors such as intramural course, slit-like origin, and acute angle take-off might be more significantly associated. Moreover, patients with coronary anomalies rarely experience cardiac events solely due to their anomaly, such as with this patient. Finally, this patient’s significantly young age at 35 years old is significant given the mean age of patients undergoing CABG being 60.8 years in one cross-sectional study. Current management of symptomatic patients with these anomalies is under debate, with many patients undergoing CABG such as in this case, although one study shows no significant difference in mortality or 10-year survival with surgical intervention despite having higher surgical intervention rates. Percutaneous coronary intervention (PCI) of patients with coronary anomalies has been shown to be difficult or unsuccessful in most studies, although a few cases in literature were successful with tools such as multidetector CT (MDCT). Awareness of these anomalies and their possible presentation, risk factors, and radiologic findings is important especially given their potential for SCD. More research is needed to further elucidate the best treatment options and perhaps even improve the potential for non-invasive interventional techniques such as PCI.

Heart rhythm complexity analysis in patients with inferior ST-elevation myocardial infarction

Heart rhythm complexity (HRC), a subtype of heart rate variability (HRV), is an important tool to investigate cardiovascular disease. In this study, we aimed to analyze serial changes in HRV and HRC metrics in patients with inferior ST-elevation myocardial infarction (STEMI) within 1 year postinfarct and explore the association between HRC and postinfarct left ventricular (LV) systolic impairment. We prospectively enrolled 33 inferior STEMI patients and 74 control subjects and analyzed traditional linear HRV and HRC metrics in both groups, including detrended fluctuation analysis (DFA) and multiscale entropy (MSE). We also analyzed follow-up postinfarct echocardiography for 1 year. The STEMI group had significantly lower standard deviation of RR interval (SDNN), and DFAα2 within 7 days postinfarct (acute stage) comparing to control subjects. LF power was consistently higher in STEMI group during follow up. The MSE scale 5 was higher at acute stage comparing to control subjects and had a trend of decrease during 1-year postinfarct. The MSE area under scale 1–5 showed persistently lower than control subjects and progressively decreased during 1-year postinfarct. To predict long-term postinfarct LV systolic impairment, the slope between MSE scale 1 to 5 (slope 1–5) had the best predictive value. MSE slope 1–5 also increased the predictive ability of the linear HRV metrics in both the net reclassification index and integrated discrimination index models. In conclusion, HRC and LV contractility decreased 1 year postinfarct in inferior STEMI patients, and MSE slope 1–5 was a good predictor of postinfarct LV systolic impairment.

Abstract 16172: Impella Use in Large Post-Infarct Ventricular Septal Rupture

Background: Ventricular Septal Rupture (VSR) is a deleterious complication associated with myocardial infarction (MI). The most common form of mechanical circulatory support (MCS) utilized in post-MI complications is intra-aortic balloon pump (IABP). Impella is a far less commonly used modality as there is the potential for right-to-left shunting and a chance of mechanical perforation of the heart. Below is a case where an Impella 5.5 catheter was necessary to bridge a patient for surgical repair. Case presentation: A 76-year-old male patient presented to an outside hospital with an acute inferior ST-elevation myocardial infarction. He was treated with thrombolysis and was emergently taken to the catheterization lab where he underwent stenting of his RCA with plan to medically manage his non-culprit disease. His hospital course was complicated by cardiogenic shock with an echocardiogram that demonstrated a large VSR (Figure 1). A right heart catheterization demonstrated a significant left-to-right shunt (Qp/Qs ratio of 6:1) which necessitated mechanical support with an IABP as per standard of care. Post-IABP his Qp/Qs ratio improved to 1.6:1 but he continued to be under supported and remained in cardiogenic shock. Surgical repair of the VSR was planned for 1-week post-MI so he was transitioned to an Impella 5.5 catheter in order to stabilize and bridge him for surgery. Patient underwent surgical VSR repair and CABG on hospital day 7. Post-op he did well and was later discharged to rehabilitation center with subsequent recovery. Conclusions: If properly managed, utilization of an Impella catheter can be an effective tool to stabilize patients in post-MI VSR with refractory cardiogenic shock and bridge patients towards surgical repair. It is particularly effective when additional MCS support is required beyond the contemporary IABP and it can be used to stabilize patients for longer durations to ultimately avoid emergent surgery.

Dialysis in Diabetic Ketoacidosis (DKA)? Profound Acidemia in the Setting of Diabetic Ketoacidosis Triggered by Inferior ST-Elevation Myocardial Infarction (STEMI)

Dialysis in Diabetic Ketoacidosis (DKA)? Profound Acidemia in the Setting of Diabetic Ketoacidosis Triggered by Inferior ST-Elevation Myocardial Infarction (STEMI)

Electrocardiographic Distinction of Culprit Artery in Patients with Acute Inferior ST Segment Elevation Myocardial Infarction and Multivessel Disease

Electrocardiographic Distinction of Culprit Artery in Patients with Acute Inferior ST Segment Elevation Myocardial Infarction and Multivessel Disease

A Case Report of Primary Angioplasty: The Triple Whammy!

Congenital anomalies involving coronary artery origin are rare, with an incidence of 0.24%–1.3%. We present a case of inferior wall ST-elevation myocardial infarction in which an emergency coronary angiogram showed occlusion of the right coronary artery. However, we were unable to cannulate the left main coronary artery during the event. Interpretation of the infarct-related artery was complicated by the right arm-left arm lead reversal in electrocardiogram, adding to the dilemma in localizing the culprit vessel, namely right versus left circumflex coronary artery-related myocardial infarction. A computed tomography coronary angiogram subsequently showed the left main coronary artery having abnormal origin from the right sinus of Valsalva with inter-arterial course and no lesions in the left circumflex.

Large Pulmonary Embolism With Paradoxical Embolism to a Coronary Artery Presenting as Inferior ST Elevation Myocardial Infarction, With Concomitant Compression of the Left Main Coronary Artery by a Dilated Main Pulmonary Artery

Large Pulmonary Embolism With Paradoxical Embolism to a Coronary Artery Presenting as Inferior ST Elevation Myocardial Infarction, With Concomitant Compression of the Left Main Coronary Artery by a Dilated Main Pulmonary Artery

Concurrent STEMI and Intracranial Hemorrhage; the Challenge

ST-elevation myocardial infarction (STEMI) and intracranial hemorrhage (ICH) conjoint presentation are alarming, necessitating a multidisciplinary approach and diligent management. Herewith we report a case of a 45-year-old male with Inferior STEMI and an ICH, highlighting the pathophysiology and complexity of this conundrum and reinforcing the need for further futuristic research in a more structured algorithmic guideline.

Develop a risk stratification model and clinical analysis to predict the impact of primary percutaneous coronary intervention on complete AV block in acute inferior STEMI patients

Background: Acute inferior ST-elevation myocardial infarction (STEMI) is medical emergency entailing immediate intervention to restore blood flow and mitigate myocardial damage. Primary percutaneous coronary intervention (PCI) has replaced thrombolytic therapy as preferred treatment strategy for having superior outcomes. Objectives: To develop a risk stratification model incorporating the identified predictors to estimate the individual risk of complete AV block in patients undergoing primary PCI for acute inferior STEMI. Methods: This study enrolled 139 patients diagnosed with acute inferior STEMI who underwent primary PCI at the hospital. They were divided into two groups, i.e. pre-operative and post-operative carrying 54 and 85 patients, respectively. On admission, demographic, clinical data and peak values of cardiac biomarkers were obtained and the complications associated with PCI were elaborated. Results: Mean age of patients was 59.81+8.19 years, and comprised significantly more male (97) than female (42) patients (p&lt;0.05). Proportion of patients with a history of complete AV block was 10.79%. Comorbidities included diabetes mellitus (33.09%), hypertension (49.64%), and dyslipidemia (64.74%).Coronary angiography findings for predicting AV block in patients with STEMI were categorized by location of culprit lesion in coronary vessels.

Prognostic value of right ventricular diastolic dysfunction in patients with inferior ST-elevated myocardial infarction

BackgroundRight ventricle infarction (RVI) is predominantly a complication of inferior wall myocardial infarction; it occurs in approximately one third of these patients. Right ventricular dysfunction in patients with inferior STEMI and RV infarction was under assessed. Nevertheless, studies which targeted RV assessment by echocardiography, did not routinely evaluate RV diastolic dysfunction. In this study, we aimed to evaluate RV diastolic dysfunction and its prognostic value in patients with inferior STEMI and RVI.ResultsSixty patients with inferior STEMI and RV infarction, who underwent primary PCI were enrolled in the study. Patients with pre-existing clinical conditions that might affect RV function, were excluded. Echocardiography was performed within twenty-four hours following the PCI, to assess the RV systolic and diastolic functions with special focus on tricuspid inflow velocities (E velocity, A velocity and E/A ratio) by pulsed wave (PW) doppler and tricuspid annular velocities by tissue doppler index (TDI) (E′, A′ and E/E′ ratio). Clinical features and MACE, including cardiogenic shock, arrhythmia, stroke, reinfarction and death were analyzed in all our patients within 3 months follow up period. The average age of the study population was 51.58 ± 10.11 years, 10% were females. Five patients developed MACE (death, cardiogenic shock and pulmonary edema, anterior STEMI and cardiogenic shock, recurrent inferior STEMI, and arrhythmia and stroke), of whom four occurred in hospital within the first 48 h. Patients who developed MACE had high filling pressures, as all of them had E/E′ > 6. E′ velocity ≤ 6 cm/sec was associated with increased MACE as 25% of patients with E′ velocity ≤ 6 had MACE compared with 2.3% of patients with E′ velocity > 6 with a p value of 0.015.ConclusionsTricuspid annular velocities by TDI are essential when evaluating RV diastolic dysfunction. E/E′ and E′ velocity have a prognostic value in patients with inferior STEMI and RV infarction; E/E′ > 6 and E′ velocity ≤ 6 cm/sec were associated more MACE in patients with inferior STEMI and RVI.

Restoration of sinus rhythm in a late presentation of inferior STEMI complicated by complete heart block with percutaneous coronary intervention

An 87-year-old female patient presented with a two-day history of the chest and epigastric pain associated with generalized fatigue. She was diagnosed with late presentation inferior ST-elevation myocardial infarction complicated by complete heart block. Given her late presentation, she was not taken to the catheterization laboratory immediately. She was admitted to the cardiac care unit. Transthoracic echocardiography showed an ejection fraction of 55% - 60% with wall motion abnormalities involving the posterior and inferior walls. A coronary angiogram the next day showed a total occlusion of the proximal segment of the RCA. Despite the uncertain benefit, taking into account the complete heart block, the artery was re-canalized with stent placement. She remained in complete heart block with stable hemodynamics. The heart team took the decision with the family to delay the insertion of a permanent pacemaker to maximize the chance of spontaneous recovery. Indeed, three days after coronary revascularization, her rhythm evolved into atrial fibrillation and two days later reverted to sinus rhythm with first-degree AV block and LAFB. She remained in normal sinus rhythm and first-degree AV block at her six months follow-up clinic visit. Data regarding the role of percutaneous intervention in patients presenting with late inferior STEMI and complete heart block is lacking. Our case illustrates the possible therapeutic role of late intervention in restoring sinus rhythm and avoiding the insertion of a permanent pacemaker.

Inferior ST segment elevation myocardial infarction combined with hyperextension cervical spine injury: A rare case report.

Inferior ST-segment elevation myocardial infarction (STEMI) is usually caused by acute occlusion of the right coronary artery or left circumflex coronary artery (LCX). Inferior STEMI can cause a high-grade atrioventricular block, sinus bradycardia, and hypotension, leading to hemodynamic collapse, syncope, and disturbance of consciousness. A case of a sudden disturbance of consciousness after chest tightness as the initial symptom, followed by incomplete paralysis and paresthesia of the extremities due to the collision of the face with the ground. Coronary angiography showed about 99% of stenosis in the LCX. Cervical spine magnetic resonance imaging showed C2/3, C3/4, C4/5, and C5/6 intervertebral disc herniation with secondary spinal stenosis, spinal cord compression, and edema. The patient was diagnosed with inferior STEMI combined with hyperextension cervical spine injury. Bivalirudin was used for anticoagulation, the LCX lesion was pre-expanded with a balloon and the thrombus was removed, and anti-platelet aggregation therapy was given postoperatively. After rehabilitation therapy, hyperextension cervical spine injury improved. There was no recurrence of syncope and precordial pain during the 6-month follow-up. Hyperextension cervical spine injury has unique hemodynamic features that mimic those associated with inferior STEMI, so a detailed medical history inquiry and physical examination should be carried out to avoid missed diagnoses.

Potential use of prophylactic intracoronary atropine in reducing reperfusion vagal reflex-related events in ST-elevation myocardial infarction

In this study, we evaluated the potential use of atropine in reducing reperfusion vagal reflex-related events during emergency percutaneous coronary intervention (PCI) for acute inferior ST-elevation myocardial infarction (STEMI). Retrospectively, we included 142 patients with inferior wall STEMI, who were treated between October 2015 and October 2020, in this study. The patients were divided into an experimental group (n = 70) and a control group (n = 72) depending on whether they received prophylactic intracoronary atropine. The experimental group was then subdivided into a low-dose group (0.5 – 1 mg atropine, n = 40) and a high-dose group (2 mg atropine, n = 30). We compared the incidence of reperfusion vagal reflex-related events and the application of temporary pacemakers between these groups. The results showed that the incidence of bradycardia (24.3% vs. 45.8%, P = 0.007), hypotension (18.6% vs. 40.3%, P = 0.005), ventricular tachycardia (4.3% vs. 19.4%, P = 0.005), and ventricular fibrillation (8.6% vs. 20.8%, P = 0.040) as well as the application of temporary pacemakers (14.3% vs. 29.2%, P = 0.032) were all much lower (all P &lt; 0.05) in the experimental group than in the control group. In addition, the incidence of bradycardia (10% vs. 35%, P = 0.016), hypotension (6.7% vs. 27.5%, P = 0.027), ventricular tachycardia (6.7% vs. 25%, P = 0.044), and ventricular fibrillation (0 vs. 15%, P = 0.034) as well as the application of temporary pacemakers (3.3% vs. 22.5%, P = 0.036) were all much lower (all P &lt; 0.05) in the high-dose group than the low-dose group. Our findings demonstrate that atropine pretreatment could prevent reperfusion vagal reflex-related events and reduce the application of temporary pacemakers during emergency PCI for acute inferior STEMI. These effects can be significantly enhanced by high-dose (2 mg) atropine pretreatment.

Question: Uncommon masquerader of inferior STEMI.

A 54-year-old man brought into the emergency department with acute onset of chest pain. He had background history of hypertension. Physical examination was notable for an elevated blood pressure of 165/85 mmHg. His chest was clear to auscultation and his heart sound did not reveal any murmur. His electrocardiograph showed inferior ST Elevation Myocardial Infarction (STEMI) as shown in Figure 1A. Patient was transferred urgently to the catheterization laboratory for coronary angiography. Ultrasound guided vascular access was obtained in the right femoral artery. JL-4 catheter was used but noted to be catching in the ascending aorta. JR-4 guide into aortic root with non-selective shot is shown in Figure 1B (see Supplementary material online, Video S1). A pigtail aortogram was performed as shown in Figure 1C (see Supplementary material online, Video S2). ... Supplementary material is available at European Heart Journal: Acute Cardiovascular Care online.