Transient Segment ST Elevation: Spontaneous Coronary Reperfusion

Author : A.Jalaludinsyah, T.Wasyanto
Upload Date : 19-04-2018

Background : Spontaneous coronary reperfusion in myocardial infarction with ST-elevation myocardial infarction (STEMI) often occurs prior to reperfusion therapy.1 Spontaneous coronary reperfusion was known to have a good effect on myocardial prognosis and viability.2 However, knowledge of appropriate management and clinical outcomes in STEMI cases with spontaneous coronary reperfusion is lacking.

Objective : To overview of diagnosis, management and clinical outcomes in patients with spontaneous coronary reperfusion.

Case Ilustration: A man came to outpatient cardiology clinic Moewardi general hospital with the chief complaint of chest pain since one weeks with ago with more frequent, severe, or prolonged than the usual pattern of angina. On electrocardiography (ECG) examination, the result was sinus rhythm with heart rate 62 times beat per minute, normoaxis, and Troponin I and CKMB markers were within normal limits. On serial examination of ECG and cardiac marker there was no changes. But the next day in the morning the patient complained of chest pain after a bowel movement, from ECG examination we found an ST segmen elevation of anterior lead. The patient was then given five mg of sublingual isosorbide dinitrate, the pain was reduced. Repeat ECG obtained ST segment elevation returned to the baseline. On invasive examination of coroangiography there was stenosis 75-80% at proximal left anterior descending (LAD) artery witth TIMI flow III, then percutaneous coronary intervention was performed with one drug-eluting stent (DES) at proximal LAD.

Discussion: Spontaneous reperfusion clinically defined as ≥70% reduction in sum ST elevation on consecutive ECGs before the administration of reperfusion therapy accompanied with ≥70% reduction in pain assessed using a visual analog Ascale of 0 to 10.3 Other studies required angiographic prove of coronary flow restoration to determine spontaneous coronary reperfusion. Steg  defined spontaneous reperfusion as restoration of TIMI 3 flow in the infarct-related artery in patients who did not receive intravenous thrombolysis and were sent to emergency coronary angiography.

Spontaneous reperfusion had a considerable incidence of recurrent in-hospital ischemia, but they tend to develop smaller myocardial infarction and had less in-hospital cardiogenic shock, heart failure, and electrical complications and had lower mortality rates in 7 and 30 days . These findings were consistent no matter what the chosen reperfusion modality was.4

Uriel (2007) compared the outcome of early cardiac catheterization (<24 hours from onset of pain) to late cardiac catheterization (>24 hours from onset of pain) in patients with clinical signs of spontaneous reperfusion.5 PCI was performed more frequently in the early group while multivessel coronary artery disease requiring CABG was seen more frequently in the late group. Myocardial infarction and angina pectoris at 30 days occurred more frequently in the early group when compared to the late group.5

Conclucion: Spontaneous coronary reperfusion was evidenced by improvement in complaints and ST segment ECG changes that returned to the baseline with sublingual isosorbid dinitrate administration only in spite of from invasive coronangiographic examination there was stenosis in LAD.

KEYWORDS : chest pain - ECG - spontaneous coronary reperfusion

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