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Inferior Linear Tissue: A Case Study

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A 65-year-old female smoker has been admitted to the hospital from the emergency department after having severe recurrent chest pain over 24 hours with positive troponin markers. Her symptoms have also been associated with intermittent palpitations. She has a positive history of 30-pack pack-year tobacco use, hypertension, and peripheral vascular disease. Her home medications include Llisinopril 40 mg once a day, cilostazol 100 mg twice per day, and lovastatin 40 mg once per day. Her admission ECG tracing shows ST-elevations in leads II, III, and AVF. Her initial vital signs are BP blood pressure 116/78 mmHg, pulse heart rate 54 beats/min, respirations rate 22 breaths /min, pulse oxygen 96% on 2 liters oxygen, and afebrile. All appropriate…show more content…
This patient has experienced an inferior wall STEMI, which has led to post-infarction conduction abnormalities. It is important to focus on the anatomy of the coronary vessels, the corresponding walls they supply, and the corresponding conducting nodes supplied. Also, one must know what walls of the heart correspond to what leads on the ECG. Inferior wall corresponds to leads II, III, and AVF. The inferior wall is predominantly supplied with blood by the right coronary artery (RCA). Other important structures that are supported predominantly by the RCA include the right ventricle and the AV node. A third-degree (or complete) heart block is the most likely tracing one would expect to see in a patient with hemodynamic instability. Management at this point, as per ACLS guidelines, starts with an initial dose of 0.5 mg of atropine IV push, repeating every 3–-5 minutes for a maximum of 3 mg if necessary. If this is ineffective, then one then must consider transcutaneous pacing. This patient had an inferior MI status post PCI bare metal stent placement into the RCA. She then moves acutely into irregular bradycardia with hemodynamic instability. The most likely post-conduction abnormality that would fit this scenario would be a third-degree AV block, which warrants a pacemaker placement after stabilization per ACLS
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