Treatment of Choice for Nonreperfused Patient in Total Atrioventricular Block Complicates Inferior Wall Myocardial Infarction with Right Ventricular Infarction
Author : P.F. Sitohang
Upload Date : 19-04-2018
Background. Total atrioventricular blocks (TAVB) complicates inferior wall myocardial infarction (IWMI) appear in 11% to 15% of all MI cases. The mechanisms are through occlusion of dominant artery and increased of vagal tone activity. IWMI with TAVB associated with poor clinical status, such as right ventricular infarction (RVI), cardiogenic shock, and atrial fibrillation. TAVB develops in inferior or posterior MI is much less dangerous, often resolving within hours to a few days. In IWMI patients with RVI and TAVB, coronary reperfusion using primary percutaneous coronary intervention (PCI) or fibrinolysis can preserve ventricular function and reduce mortality and morbidity. Bradyarrhythmia with hypotension and TAVB is one of the main priorities to get temporary pacing.
Methods. This is a case of a gentleman who developed infero-posterior wall myocardial infarction, RVI, with TAVB. He was suggested to get primary PCI or fibrinolysis and temporary pacing, but he refused due to cost reasons. For bradycardia and hypotension, atropine sulfate and dopamine was given. And for antithrombotic therapy, dual-antiplatelet therapy with aspirin and clopidogrel along with fondaparinux was given to the patient.
Results. After 48h, his ECG showed resolution of STEMI and improvement in heart rhythm with first-degree AVB and stable hemodynamics. He was observed in hospital for 4 more days. At 3 months follow-up, he was asymptomatic, had no evidence of AV block on ECG.
Conclusion. In nonreperfused patients, an appropriate antithrombotic regimen needed to overcome this condition. Fondaparinux given along with dual-antiplatelet therapy (aspirin and clopidogrel) provide significant benefit, and their use in these patients is supported by both current European and North American STEMI guidelines. Bradyarrhythmias due to TAVB in IWMI (within the first 24 hours) may respond to atropine, dopamine can be used as an alternative if does not respond.
KEYWORDS : Inferior wall myocadial infarction, nonreperfused patients, right ventricular infarction, total atrioventricular blocks