ST segment elevation during Treadmill exercise test in a patient without prior Myocardial Infarction
K. Sangeetha.
Cardiac Technician, Heart city, Trichy
Abstract
Exercise induced ST –Elevation is extremely uncommon especially in patient without prior Myocardial Infarction it is more common among post infarction patient with Q waves on the resting ECG. In the current case we report a 65 – years old man with a history of chest discomfort on exertion started 4 days ago. During the exercise test, ST –Elevation was observed in leads II, III, AVF. Coronary angiography revealed Double vessel disease + Branch vessel disease and underwent primary PTCA with Stenting to proximal LCX to OM which were treated with percutaneous coronary intervention. After Elective PTCA with stenting to proximal to mid LAD and Diagonal (Release R 2.75 x 24 mm) & (Release R 2.5 x 18 mm) this case highlights the rare finding of exercise induced ST-Elevation and reviews possible mechanisms.
Introduction
Exercise stress testing has been regarded as the optimum method for the Identification of myocardial ischemia. Now a day, the method sensitivity as well as specificity in the confirmation of ischemia has been greatly enhanced both by complying with more standardized protocols and the advance of mechanical equipment.
Case Presentation
A 65 years old man, with history diabetes and hypertensionon, had complaints of chest discomfort since a day
Clinically stable
Resting ECG
Within normal limits
ECHO: Concentric LVH
TMT: ST Elevation in Inferior leads
Opinion
He was advised Coronary Angiography
Coronary Angiography and PTCA
Left Anterior Descending Artery Type III LAD, Proximal to mid LAD has 60 % stenosis. The RCA Non Dominant mid to distal LCX has 20 % stenosis. Neither thrombus, during coronary angiography the patient received intracoronary nitrites without improving the angiographic grade of the stenosis. Double vessel disease + Branch vessel disease. Right radial artery was accessed by the modified seldingers technique. The LMCA was engaged using a 6 F EBU 3.5 guiding catheter. The proximal LCX to OM lesion was crossed using a run through 0.014 ×180 cm guide wire. The lesion was predilated using a ryurei 2 × 10 mm balloon at 12 atmospheres 20 seconds. A synergy 3 × 48 mm stent was optimally positioned across the LCX to OM lesion and was deployed at 12 atmospheres 20 seconds. Post deployment check angiography revealed optimally positioned and well deployed stent with mild residual stenosis.
Then the mild residual stenosis was dilated using a NC Quantum apex 3.5 × 12 mm balloon at 18 atmospheres for 20 seconds. Post dilatation check angiography revealed well dilated stent with TIMI III distal flow and no residual stenosis. Successfully Primary PTCA and stenting to proximal LCX to OM (des) with optimal results. There was no procedural and post procedural complications and his post procedural period was uneventful. Patient was treated with antiplatelet, IV anticoagulants, statins, hypoglycaemic agents, PPI and other supportive measures. Nature of the disease and risk of restenosis were well explained to patient attenders. Patient condition is improved and is being discharged in a stable state.
PLAN: Staged PCI LAD / D1 (2 stents)
- Right radial artery was accessed by the Modified Slingers technique. The LMCA was engaged using a 6 F EBU 3.5 guiding catheter. The proximal to mid LAD lesion was crossed using a 0.014 x 180 cm Run-through guide wire. The lesion was predilated using a Ryrie 2 x 10 mm balloon at 12 atmospheres 20 seconds. A release R 2.75 x 24 mm stent was optimally positioned across the LAD lesion and was deployed at 12atmospheres 20 seconds. Post deployment check angiography revealed optimally positioned and well deployed stent with mild residual stenosis.
- Then the mild residual stenosis was dilated using a Accuforce 3 x 8 mm balloon at 18 atmospheres for 20 seconds. post dilatation check angiography revealed well dilated stent with TIMI III distal flow and no residual stenosis.
- Right radial artery was accessed by the Modified Seldingers technique. The LMCA was engaged using a 6 F EBU 3.5 guiding catheter. The diagonal lesion was crossed using a 0.014 x 180 cm Run-through guide wire. A release R 2.5 x 18 mm stent was optimally positioned across the diagonal lesion and was deployed at 12atmospheres 20 seconds. Post deployment check angiography revealed optimally positioned and well deployed stent with mild residual stenosis.
- Then the mild residual stenosis was dilated using an Accuforce 2.5 × 8 mm balloon at 18 atmospheres for 20 seconds. Post dilatation check angiography revealed well dilated stent with TIMI III distal flow and no residual stenosis.
- Final Report: Successful Elective PTCA and Stenting to Proximal to Mid Lad and Diagonal (Des) with optimal results.
Outcome
On discharge, Patient was hemodynamically stable.
Conclusion
In conclusion, ST Elevation during exercise stress test TMT is rare but has significant predictive value. Urgent coronary angiography should be performed for further diagnosis and management.
List of Abbreviations
- CAD = Coronary Artery Disease
- ECG = Electrocardiography
- MI = Myocardial Infarction
- PCI = Percutaneous Coronary Intervention
- TIM I = Thrombolysis in Myocardial Infarction
- RCA = Right Coronary Artery
- LAD = Left Anterior Descending Artery.
Ms. K. Sangeetha.
Cardiac Technician