Thread by @shahrukh_bakar

@EM_VATA @JdBapttiste @bwoody58 @dr_benoy_n_shah Learning points:
1) ongoing pain is a MAJOR red flag, regardless of ECG. Cath immediately without delay.
2) Q waves do NOT mean non-viable myocardium. They can develop early during ischemia.
3) Hypokinesis/akinesis does NOT imply that the myocardium is non-viable

@EM_VATA @JdBapttiste @bwoody58 @dr_benoy_n_shah 4) It takes ischemia of only 20% of wall thickness to generate a wall motion abnormality on echo.
5) There is nothing to gain and everything to lose by sitting on such a patient and delaying cath.
6) Beware opiates given to such patients which can mask pain. Use nitro first.

@EM_VATA @JdBapttiste @bwoody58 @dr_benoy_n_shah 7) If pain not going away with nitro, electrical instability, or rapid onset of HF, emergent cath is critical. Do NOT mask with morphine. If there’s a patient with ongoing pain after three rounds of NTG, I want to hear about it even at 0300.
8) Contrast-enhanced TTE imperative

@EM_VATA @JdBapttiste @bwoody58 @dr_benoy_n_shah 9) I feel that sometimes we as interventionalists are not called early about such patients and/or we don’t inquire enough about the factors above; the patient suffers, and to find an occluded LAD this late into ER presentation should prompt a system review between hospitals

@EM_VATA @JdBapttiste @bwoody58 @dr_benoy_n_shah 10) whoever was called to review this case in the receiving hospital needs to be involved in the discussion. No ST elevation does NOT equal no cath. Unfortunately some people have this mindset and it leads to irreparable harm.

@EM_VATA @JdBapttiste @bwoody58 @dr_benoy_n_shah 11) It breaks my heart to hear about such cases because the majority of the benefit of PPCI has been lost and the pt suffers. I try to promote a sense of safety and friendliness with my referring docs. They know and are actively encouraged to call me early

@EM_VATA @JdBapttiste @bwoody58 @dr_benoy_n_shah 12) if nothing else, I hope that this case will promote some system review and feedback. It should be treated as seriously as a missed anterior STEMI. Sorry to sound blunt and dogmatic.

@EM_VATA @JdBapttiste @bwoody58 @dr_benoy_n_shah 13) Do NOT be reassured by spontaneously fluctuating pain. Any pain > 0/10 is a problem. Ditto post-TNK even with > 50% STE resolution. Again, ANY pain means take to lab immediately if not improved after some nitro.